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TEXT-BOOK 



OF 



GYNECOLOGY 



DESIGNED FOR THE 



STUDENT AND GENERAL PRACTITIONER 



•/ 



^ 



^ 



BY 



A^ C. COWPERTHWAITE, MP., Ph.D.. LL.D. 



Professor of Materia Medica and Diseases of Women in the Homoeopathic Medical 

Department of the University of Iowa : President of the American Institute 

of Homoeopathy; Author of "A Text-Book of Materia Medica:" 

"Insanity in its Medico-legal Relations." etc., etc. 




CHICAGO: 
GROSS & DELB RIDGE 

18 8 8. 



Copyrighted 1888. 

By GROSS & DELBRIDGE. 

All rights reserved. 



F. GROSKREUTZ, PRINTER. A. J. COX & CO.. BINDERS, 

CHICAGO. CHICAGO. 



TO 

THE ALUMNI 

OF THE 

HOMCEOPATHIC MEDICAL DEPARTMENT 

OF THE 

STATE UNIVERSITY OF IOWA. 

WHOSE SOLICITATIONS FIRST PROMPTED ME TO UNDERTAKE 
THE LABOR OF ITS PREPARATION, 

THIS VOLUME 

IS RESPECTFULLY DEDICATED BY THEIR FRIEND, 

The Author. 



PREFACE. 



In presenting this book to the profession a word of explana- 
tion, and. perhaps, of apology, is appropriate. 

During the eleven years that it has been my privilege to fill 
the chair of Gynecology in the State University of Iowa, I have 
seriously felt the need of a text-book for students that would 
be systematic in its arrangements, concise in its details, and cover 
the entire list of diseases comprehended by the term " gynecology ;" 
together with their homeopathic therapeutics. After long waiting 
in the hope that some one better qualified would assume the un- 
enviable task of preparing such a work. I have, at the earnest 
solicitation of students and professional friends, taken it upon 
myself to make the attempt, and the present volume is the result 
of my labors. That I have presented nothing strikingly new or 
original is probably true, but I have endeavored to collate only 
from recognized authorities, and to include the very latest that 
is known regarding the pathology and treatment of gynecological 
diseases. 

It will possibly be urged by some that I have paid too much 
attention to the local treatment of uterine diseases, and too little 
to their therapeutics. While I am convinced that these diseases 
are often due to mal-nutrition. and other constitutional causes, and 
are. therefore, only to be combated by careful internal medica- 
tion, nevertheless, after twenty years' experience. I am satisfied 
that a large majority of cases of uterine disease can be successfully 
overcome only by a judicious combination of both constitutional 
and local treatment, and it is my opinion that the opposite view 



vi PREFACE. 

is entertained only by theorists, who have had little or no practical 
experience in the treatment of cases of this class. In some 
instances I have named only the remedies most often used in a 
certain disease, referring the reader to the materia medica for 
individual indications, which I believe to be the proper method ; 
but in most cases I have given briefly the chief indications for the 
leading remedies. The successful gynecologist must carefully study 
his materia medica, in every case, and not depend too much upon 
a few characteristic indications, which, isolated from other symp- 
toms, may sometimes prove to be misleading. 

Fully realizing the imperfections of the work, yet hoping 
that it may fulfill the purpose originally intended, I now submit 
it to the profession. 

A. C COWPERTHWAITE. 

Iowa City, Iowa, September 20, 1888. 



CONTENTS. 



CHAPTER I. 

Page. 

Anatomy of the Genital Organs . . . . . . . 1 

CHAPTER II. 
General Etiology of Gynecological Diseases .... 25 

CHAPTER III. 
Examination and Diagnosis of Gynecological Diseases . . 29 

CHAPTER IV. 
Instrumental Examination 39 

CHAPTER V. 
Diseases of the Vulva 64 

CHAPTER VI. 
Tumors of the Vulva 68 

CHAPTER VII. 

Varicose Veins ; (Edema ; Eruptive Diseases ; Pruritus Vulvae 74 

CHAPTER VIII. 
Vulvitis 81 

CHAPTER IX. 
Diseases of the Vagina 90 

CHAPTER X. 

Vaginitis ; Vaginismus ■ . . . .97 

CHAPTER XL 
Prolapsus Vagina ; Cystocele ; Rectocele ; Enterocele . . 103 

CHAPTER XII. 
Treatment of Prolapsus and Hernia of the Vagina . . .107 

vii 



viii CONTENTS. 

CHAPTER XIII. 

Page. 

Vaginal Fistula ..... 122 

CHAPTER XIV. 

Diseases of the Uterus; Malformations; Atrophy; Hypertrophy 

of the Cervix 137 

CHAPTER XV. 

Atresia of the Cervix; Stenosis of the Cervix . . . .148 

CHAPTER XVI. 
Laceration of the Cervix 153 

CHAPTER XVII. 
Chronic Cervical Endometritis . 161 

CHAPTER XVIII. 

Chronic Corporeal Endometritis . . . . . .167 

CHAPTER XIX. 

Acute Metritis 174 

CHAPTER XX. 

Chronic Metritis; Subinvolution . 177 

CHAPTER XXI. 

Treatment of Chronic Metritis, Endometritis and Peri-Uterine 

Inflammations by Electricity 186 

CHAPTER XXII. 
Displacements of the Uterus . . . . . . . .197 

CHAPTER XXIII. 
Anteversion ; Retroversion ; Lateroversion . 210 

CHAPTER XXIV. 
Anteflexion 220 

CHAPTER XXV. 
Retroflexion ; Lateroflexion 226 

CHAPTER XXVI. 
Inversion of the Uterus 236 



CONTENTS. ix 

CHAPTER XXVII. Page 

Fibroid Tumors of the Uterus ,244 

CHAPTER XXVIII. 
Diagnosis and Prognosis of Fibroid Tumors . 252 

CHAPTER XXIX. 

Treatment of Fibroid Tumors ........ 256 

CHAPTER XXX. 

Treatment of Fibroid Tumors by Electricity . . 265 

CHAPTER XXXI. 
Mucous Polypi of the Uterus „ 273 

CHAPTER XXXII. 

Sarcoma of the Uterus . 277 

CHAPTER XXXIII. 
Carcinoma of the Uterus .280 

CHAPTER XXXIV. 

Diseases of the Uterine Ligaments 394 

CHAPTER XXXV. 

Diseases of the Fallopian Tubes 297 

CHAPTER XXXVI. 

Diseases of the Ovaries 304 

CHAPTER XXXVII. 
Ovarian Neuralgia 308 

CHAPTER XXXVIII. 
Inflammation of the Ovaries 311 

CHAPTER XXXIX. 
Ovarian Tumors 316 

CHAPTER XL. 
Cystic Tumors of the Ovary . . . . . . . " . 318 

CHAPTER XLI. 
True Cysts of the Ovary 323 



x CONTENTS. 

CHAPTER XLII. Page 

Etiology, Natural History and Symptoms of Ovarian Cysts . 329 

CHAPTER XLIII. 
Diagnosis of Ovarian Cysts . .333 

CHAPTER XLIV 
Treatment of Ovarian Cystic Tumors 341 

CHAPTER XLV. 
Ovariotomy 348 

CHAPTER XL VI. 
Pelvic Peritonitis . ■ 364 

CHAPTER XL VI I. 
Pelvic Cellulitis 370 

CHAPTER XL VIII. 
Pelvic Abscess 382 

CHAPTER XLIX. 
Pelvic Hematocele . 386 

CHAPTER L. 

Amenorrhea . . . . . ....... 394 

CHAPTER LI. 
Menorrhagia 399 

CHAPTER LIT 

Dysmenorrhea ............ 406 

CHAPTER LIII. 
Leucorrhea . . . : _ . • • • • • • 419 

CHAPTER LIV. 
Chlorosis 428 

CHAPTER LV. 
Hysteria 433 

CHAPTER LVI. 
Sterility 444 



CONTENTS. xi 

CHAPTER LVII. Page 

Extra-Uterine Gestation . 450 

CHAPTER LVIII. 
Treatment of Extra-Uterine Gestation 461 

CHAPTER LIX. 
Diseases of the Mammary Glands 469 

CHAPTER LX. 

Mastitis; Mastodynia 473 

CHAPTER LXI. 

Tumors of the Mammary Gland 484 

CHAPTER LXII. 
Malignant Tumors of the Mammary Gland . . . . 495 

CHAPTER LXIII. 
Carcinoma of the Mammary Gland 503 

CHAPTER LXIV. 

Treatment of Carcinoma of the Mammary Gland . . .514 

APPENDIX. 

Dry Heat in the Treatment of Uterine Disease. By Phil. Porter, 

M.D 520 

Dr. Wathen's Serrated Scissors and Compound Tenaculum . 523 

New Abdominal Electrode 525 



LIST OF ILLUSTRATIONS. 



Fig. Page. 

1. External genitals of virgin 2 

2. Section of female pelvis (Spiegelberg) ...... 3 

3. Front view of perineal septum .4 

4. Lateral view of perineal septum ,5 

5. Anterior wall of the vagina (Henle) 6 

6. Internal organs of generation (Biegel) 8 

7. Transverse section of body above fundus uteri (Savage) . . .9 

8. Anterior view of virgin uterus (Sappey) 10 

9. Median and transverse sections of virgin uterus . . . .11 

10. Normal positions of the uterus (Yan de Warker) .... 13 

11. Normal form and position of virgin uterus (Schultze) . . .15 

12. Ovary and Fallopian tube 17 

13. Longitudinal section of ovary 18 

14. Vertical section through ovary of a bitch ( Waldeyer) ... 19 

15. Diagrammatic section of Graafian follicle .20 

16. Diagrammatic representation of pelvic peritoneum (Ranney) . 20 

17. Arterial vessels in a uterus ten days after delivery . . . .21 

18. Nerves of the uterus (Frankenhasuser) .22 

19. Uterine and utero-ovarian veins 23 

20. 21, 22, 23. Sharp & Smith's combined office chair ... 32, 33 

24. Bi-manual examination (Hart) 36 

25. Anterior abdominal surface in bi-manual . . . .37 

26. Fergusson's speculum . . 39 

27. Nelson's speculum . . 40 

28. Nott's speculum 40 

29. Cusco's speculum . . .41 

30. Miller's speculum . . 41 

31. Hale's speculum 41 

32. Jackson's speculum .42 

33. Graves' speculum . 42 

34. Sims' speculum 42 

35. Sims' depressor 43 

36. Simon's speculum 43 

37. Simon's retractor or plate 44 

38. Simon's flat steel hooks .44 

38£. Porter's speculum 45 

39. Jackson's modified Sims' speculum . . . . . .45 

40. Emmett's perineal retractor .46 

41. Hunter's speculum . 46 

42. Dawson's speculum ,46 

43. Manns' speculum . 47 

xii 



LIST OF ILLUSTRATIONS. 



Xlll 



Fig. 

44. Simpson's uterine sound 

45. Thomas' uterine sound 

46. Fitch's uterine sound 

47. Sims' uterine sound 

48. Jenk's uterine sound 

49. Tupelo tents before and after expansion (Munde) . 

50. Slippery elm tents 

51. Tent applicator 

52. Molesworth's uterine dilator 

53. Emmett's water dilator ....... 

54. 55, 56, 56^. Allen's surgical pump 

57. Tait's uterine dilator 

58. Hank's uterine dilator 

59. Graduated steel sounds 

60. Goodell's modified Ellinger dilator .... 

61. Truax's modified Ellinger dilator ... 

62. Sims' uterine dilator - 

63. Palmer's uterine dilator 

64. Recauner's curette 

65. Sims' curette 

66. Simon's curette 

67. Thomas' dull wire curette . . ' 

68. Byford's curette 

69. Aspirator 

70. Peaslee's aspirator 

71. Aspirator needles for Allen's surgical pump 

72. Hypospadias (Winckel) 

73. Epispadias (Winckel) 

74. Cyst of the vulvo-vaginal glands 

75. Elephantiasis of the labia (Scanzoni) .... 

76. Follicular vulvitis 

77. Urethral caruncle, and neuromata (Sir J. Y. Simpson) 

78. Sims' glass vaginal plug 

79. Peaslee's perineum needle 

80. Goodell's perineum needle . . 

81. Skeene's perineum needle 

82. Jenk's perineum scissors 

83. Needle with short lateral curve . . . 

84. Surface denuded in perineal rupture 

85. Perineum freshened with sutures introduced . 

86. Lines of incision in triangular flap operation (Hart & Bar 

87. Flaps raised and sutures passed in same operation (H. & 

88. Perineal surface denuded and sutures in position 

89. Elytrorrhaphy — Sims' method of denudation . 

90. Elytrorrhaphy — Emmett's method of denudation 

91. Thomas' dilating forceps 

92. Thomas' vaginal clamp 

93. Diagram of principal varieties of vaginal fistulas 

94. Bozeman's apparatus 



bour 
B.) 



Page. 

47 
. 49 

49 
. 49 

50 

51 

52 
. 52 

53 

. 53 

53, 54, 55 

. 56 

56 
. 56 

58 
. 58 

59 
. 59 

59 
. 59 

60 
. 60 

60 
. 61 

62 
. 62 

64 
. 65 

68 
. 70 

84 



96 
108 
108 
108 
110 
111 
112 
113 
115 
115 
116 
117 
118 
119 
120 
122 
126 



XIV 



LIST OF ILLUSTRATIONS. 



& K.) 



Fig. 

94£. Comstock's gynapod 

95. Tenacula . . . . . . . 

96. Method of paring edges of fistula? (Simon) 

97. Long handled curved scissors 

98. Emmett's curved scissors .... 
98£. Emmett's double curved scissors . 

99. Knives for paring fistulas . 

100. Sims' rotary knife 

101. Laterally curved needles on fixed handles 

102. Hollow or tubular needles .... 

103. Bozeman's fork 

104. Blunt hook . . 

105. Passing needle in vesico-vaginal fistulas . 

106. Twisting sutures in vesico-vaginal fistulas . 

107. Sims' wire adjuster . . . * . 

108. Emmett's twisting forceps .... 

109. Fistula with edges pared and sutures placed 

110. Sims' sigmoid catheter 

111. Sutures passed through anterior lip of cervix (H. 

112. Simon's operation for kolpokleisis (H. & K.) 

113. Uterus with double cavity ... 

114. Uterus septus bilocularis (Cruveilhier) 

115. Double uterus and vagina (Courty) 

116. Diagram of amputation of cervix 

117. Hysterotome 

118. Peaslee's uterotome . . . . 

119. Thomas' glass cervical plug 

120. Wylies' cervical plug ..... 

121. Single laceration of cervix (Emmett) 

122. Multiple laceration of cervix (Emmett) 

123. Emmett's double tenaculum 

124. Extent of denuded surface in operation for lacer: 

125. Russian needle-holder 

126. Extent of denuded surface and course of sutures (Emmett) 

127. Mode of passing sutures 

128. Appearance of cervix with sutures twisted 

129. Jackson's cervical needle 

130. Jennison's douche • . . 

131. Diagram showing nature of prolapsus uteri (Schultz) 

132. Diagram showing stages of prolapsus uteri 

133. Hodge's pessary 

134. Thomas' modification of Hodge's pessary . 

135. Emmett's modification of Hodge's pessary 

136. A. Smith's modification of Hodge's pessary 

137. Fowler's pessary 

138. Meig's ring pessary 

139. Thomas' modification of Meig's ring pessary 

140. Zwanck's pessary . . 

141 . Anteversion of the uterus .... 



ated cervix 



Page. 
127 
127 
128 
128 
129 
129 
129 
130 
130 
130 
130 
131 
131 
132 
132 
132 
133 
133 
134 
135 
139 
140 
141 
146 
151 
152 
152 
152 
153 
154 
157 
158 
158 
159 
159 
159 
160 
171 
199 
200 
207 
207 
207 
207 
207 
208 
208 
208 
210 



LIST OF ILLUSTRATIONS. 



xv 



Fig. 

142. Graily Hewitt's cradle pessary 

143. Gehnmg's anteversiou pessary . 

144. Thomas' anteversion pessary 

145. Hitchcock's anteversiou pessary 

146. Retroversion of the uterus 

147. Guernsey's uterine elevator 

148. Elliott's uterine repositor 

149. Sims' uterine repositor 

150. Thomas' retroversion pessary 

151. Hoffman's retroversion pessary 

152. Byf orcl's retroversion pessary 

153. Anteflexion of the uterus 

154. Chapman's intra-uterine stem pessary . 

155. Jackson's elastic stem pessary 

156. Sims' division of cervix 

157. Retroflexion of the uterus .... 

158. Replacement of the uterus with the sound . 

159. Thomas' retroflexion pessary 

160. Thomas' modification of Cutter's pessary 

161. Thomas' lateroflexion pessary 

162. Inversion of the uterus 

163. Stages and degrees of inversion of the uterus 

164. Reposition of the uterus with the hand alone 

165. White's repositor 

166. Tait's method of making counter-pressure . 

167. Cup with stem and elastic bands .... 

168. Emmett's method of retaining partial inversion 

169. Typical varieties of fibro-myomata .... 

170. Enormous cystic myoma 

171. Aveling's polypotome ...... 

172. Chassaignac's ecraseur 

173. Volsellum forceps 

174. Emmett's enucleator . . . 

175. Thomas' spoon saw 

176. Group of mucous polypi in cervix 

177. Glandular polypus 

178. Uterine polypus forceps with catch 

179. Cauliflower excrescence of cervix (J. Y. Simpson) 

180. Tubal dropsy (Boivin and Duges) .... 

181. Munde's pessary for prolapsed ovary 

182. Dermoid cyst of right ovary . 

183. Bone resembling lower jaw taken from dermoid cy 

ovary 

184. Ovary with dropsical follicles .... 

185. Diagram showing dull area in ovarian tumor and 

(Barnes) . 

186. Wells' ovarian trocar 

187. Emmett's ovarian trocar 

188. Nelaton's forceps 



st of left 



ascites, 



Page. 
212 
212 
213 
213 
214 
216 
217 
217 
218 
218 
219 
220 
224 
224 
225 
226 
231 
232 
233 
234 
236 
236 
240 
241 
241 
242 
243 
247 
250 
260 
260 
261 
261 
262 
273 
274 
275 
287 
300 
306 
320 

320 
322 

337 
355 
356 
356 



XVI 



LIST OF ILLUSTRATIONS. 



Fig. Page. 

189. Wells' ovarian clamp . 357 

190. Thomas' ovarian clamp . 358 

191. Dawson's ovarian clamp 358 

192. Paquelin's thermo-cautery 359 

193. Sketch of a clysmenorrheal membrane 410 

194. Dysmenorrheal membrane laid open 411 

195. Tubal gestation 450 

196. Tubal gestation 451 

197. Interstitial gestation 452 

198. Lithopaedion . . . 453 

199. Abdominal gestation . 454 

200. Gestation in rudimentary horn 455 

201. Enormous lipoma behind right mamma (Billroth). . . . 487 

202. Hypertrophy of both breasts, girl 16 years old (Billroth) . . 490 

203. Hypertrophy of both breasts, woman 22 years old (Billroth) . 491 

204. Mamma with many small cysts 492 

205. Compound cystoma 493 

206. Section of a proliferous cysto-sarcoma (Billroth) . . . 498 

207. Enormous cysto-sarcoma of the mamma (Velpeau) . . . 498 

208. Myxomatous and telangiectatic cystic small spindle-celled 

sarcoma (Gross) 499 

209. Atrophying scirrhus of the right mammary gland .... 504 

210. Local dissemination and superficial ulceration of scirrhous car- 

cinoma 507 

211. Local dissemination and deep ulceration of scirrhous carcinoma . 508 

212. Porter's^dry heater for the uterus and bladder .... 520 

213. Porter's dry heater for the vagina and rectum .... 520 

214. Wathen's serrated scissors 524 

215. Wathen's compound tenaculum ..... . . 524 



A TEXT-BOOK OF GYNECOLOGY. 



CHAPTER I. 



ANATOMY OF THE GENITAL ORGANS. 

Before attempting to study the pathology of an organ it is of 
the utmost importance that an accurate knowledge be obtained of 
that organ while it is in a state of health. If we do not know the 
normal size, shape or position of the uterus we are poorly fitted to 
recognize abnormal conditions which are chiefly manifested by 
changes in its size, shape or position. If we cannot tell how the 
uterus feels to the touch, or if we are ignorant of the appearance 
it presents to the eye when in its normal condition, we are not 
competent to diagnosticate a departure from that condition. It is 
essential, therefore, to present to the student at the outset the most 
important features of the surgical anatomy of the reproductive 
organs in the female. This will be done as briefly as possible, 
leaving a greater elaboration of the subject to more exhaustive 
treatises. 

The Vulva includes what are known as the external gen- 
itals, which consist of the mons veneris, the clitoris, the vesti- 
bule and the fossa navicularis. For convenience the meatus uri- 
narius and hymen are also described with these, although the 
former belongs to the urinary system, and the latter separates 
anatomically the vulva from the vagina, or the external from the 
internal genitals. 

The Mons Veneris, or "mount of love," is the name given 
to a rounded eminence situated in front of the pubes, above the 
vulva, The eminence is made up in part of the projection of the 
bones, and partly of the adipose tissue which forms a cushion 
under the skin. At the epoch of puberty it is covered with hair. 

The Labia Majora are two prominent folds of skin which 
bound the orifice of the vagina. Flattened transversely, thicker 
above than below, they present in the adult an external aspect 
covered with hair, and an internal aspect moist and smooth, con- 
tiguous with the corresponding aspect of the opposite labium. 
The anterior, or upper, extremity is continuous with the mons 
veneris, and the lower, or posterior, extremity unites with that of 



2 A TEXT-BOOK OF GYNECOLOGY. 

the opposite side to form the fourchette. The space between the 
fourchette and the anus constitutes the perineum, which is usually 
about an inch in length. The substance of the labia consists of 
fat, blood-vessels and dartos, the latter being analogous to the 
dartos in man, which is considered to establish an analogy between 
the labia majora and the male scrotum. 

The Labia Minora, or nymphse, are two small, oblique 
folds of skin arising from the inner aspect of the labia majora at 




Fig. 1. External Genitals of Virgin with Diaphragmatic Hymen. The 
Labia. Majora and Minora are drawn apart, and the prepuce drawn 
back. The cadaver is in the lithotomy posture (modified from Sappey): 
a, Labium majus; 6, Labium minus; c, Praeputium clitoridis; d, Glans 
clitoridis; e, Vestibule just above urethral orifice; /, Mons Veneris. 

about the middle, converging anteriorly, and each dividing into 
two small branches. The upper branches meet and form a hood- 
like fold, which is the prepuce of the clitoris, while the lower 
branches are attached to the clitoris, and form its suspensory 
ligament. The surfaces of the labia minora are smooth or slightly 



ANATOMY OF THE GENITAL ORGANS. 3 

roughened, and their free border is convex, nearly acute, and 
often slightly notched. In the child the nymphse project beyond 
the labia majora, but when normal in size, this does not occur in 
the adult. Their substance consists of a non-adipose tissue, and 
large bundles of elastic fibres anastomosing in a network. 
Sebaceous glands, analogous to those of the internal aspect of the 
labia majora, but smaller, open on both surfaces, but principally 




Fig. 2. — Section of female pelvis. 1, rectum. 2, uterus. 3, cul-de-sac of 
Douglas. 4, vesico-uterine space. 5, bladder. 6, clitoris. 7, urethra. 
8, symphysis. 9, sphincter ani. 10, vagina. (Kohlrausch modified by 
Spiegelberg.) 

on the internal surface, where they form a very crowded layer. 
Their vascular supply is well developed, and is obtained from 
branches of the internal pudic artery. 

The Clitoris is a small, curved, rudimentary, erectile organ, 
analogous to the male penis, terminating in a small, imperforate 
glans, the glans clitoridis. Covered by its prepuce, before men- 



4 A TEXT-BOOK OF GYNECOLOGY. 

tioned, it lies in the middle line and at the apex of the vestibule. 
The glans is the only part visible under normal conditions, and 
varies in size from that of a small shot to a pea, in some cases 
being so small as to elude discovery without careful search. In 
exceptional cases the organ is excessively developed, and may 
appear in size and form very much like the male penis, such cases 
having been reported as instances of hermaphrodism. In some 
women the clitoris is not easily excited, while in others erection 
takes place readily, the organ becoming distinctly arched and 




Fig. 3. — Front View of Perineal Septum, showing entire clitoris (Savage): 
1, clitoris; 2, suspensory ligament; 3, crura of clitoris; 4, subpubic liga- 
ment; 5, dorsal vein of clitoris; 6, perineal septum; 7, superficial 
transverse muscle; U, urethra; V, rectum and vagina; P, site of per- 
ineal body. 

assuming the character of a firm, hard cord, while the glans sensi- 
bly protrudes. The organ arises by two roots from the ischio- 
pubic rami, which unite superiorly to form the body of the 
clitoris, which lies beneath the mucous membrane. The glans is 
not directly continuous with the body, but has the appearance of 
a bulb. 

The Vestibule is a triangular, smooth, mucous surface, 
bounded superiorly by the clitoris, laterally by the labia minora, 
and inferiorly by the upper margin of the vaginal orifice. In the 



ANATOMY OF THE GENITAL ORGANS. 



middle line, at its base, the dimple of the urethral orifice can be 
distinctly felt in front of the fourchette. Small depressions and 
mucous glands open on its surface. 

The Fossa Naviculars is the space which separates the 
fourchette from the entrance of the vagina, the posterior boundary 
being the inner aspect of the fourchette, and the anterior being 
the posterior aspect of the hymen. 

The Hymen is a fold of mucous membrane separating the 
external from the internal genitals. It is usually thin and easily 
ruptured, and in early virginity partially closes the vulvar orifice. 
It is often of a crescentric shape, and thicker at the sides where it 



Fig. 4. — Lateral view of the erectile 
structures of the female external organs. 
The skin and mucous membrane hare 
been removed and the blood vessels in- 
jected, a, bulbus vestibuli ; v, plexus of 
veins called the pars intermedia; e, glans 
clitoridis ; f, corpus clitoridis; 7i, dorsal 
vein; I, right cms clitoridis; m, vestibu- 
lum ; n, right gland of Bartholin or Du- 
verney. 



is attached. At one time its presence was considered to be a 
proof of virginity, but this idea has long been exploded. In a 
healthy woman who has experienced complete coitus it is usually 
torn, though sometimes only stretched. In a woman who has 
borne children it is always torn. In a female infant the hymen 
exists only in a rudimentary form. In some young women it 
never becomes fully developed, and in many others its growth is 
arrested after attacks of measles or scarlet fever. In a few rare 
cases the hymen has been found fully formed and imperforate in 
new-born infants. 

The Vagina is the organ of copulation in woman, and at the 
same time serves as a canal for the passage of the menstrual and 
other fluids, and the products of conception. It is a membranous 
canal or collapsed tube extending in from the vulva to the uterus, 
and lying between the urethra and bladder in front, and the rec- 
tum behind. Its lower limit is marked out by the hymen, which 
also marks the anatomical division between the external and the 
internal genitals, the latter commencing with the vagina. 




A TEXT-BOOK OF GYNECOLOGY. 



The vagina is from four to five inches in length, and has an 
anterior and a posterior wall, the anterior being shorter than the 
posterior. Both walls are triangular in shape, with the base 
upward and backward. The anterior wall extends from about 
the urethra, with which it is intimately related, backward and 
upward under the bladder, with which it is united by loose con- 
nective tissue, and is finally reflected down a short distance on the 
anterior lip of the cervix, the anterior fornix being thus formed. 
In the same manner the posterior wall extends from the vaginal 

orifice upward, and is reflected upon 
the cervix, forming the posterior for- 
nix, which is deeper than the anterior. 
The anterior wall is straight, but the 
posterior wall is curved, the curve vary- 
ing according to the position of the ute- 
rus and the amount of distention of the 
bladder and rectum. The vagina is, 
therefore, a curved canal, the posterior 
wall of which is longer than the ante- 
rior, so that in making a vaginal exam- 
ination the finger reaches the anterior 
fornix more readily than the posterior. 
The whole canal has been likened to a 
flexible tube shortened anteriorly by a 
cord passed from end to end through 
one of its sides. This would corru- 
gate the shortened side, and we find 
that while the mucous membrane of 
both the anterior and posterior walls is 
arranged in transverse rugous folds, 
that of the anterior wall is much rougher 
and more rugous than the posterior. 

According to Hart and Barbour (1) 
4 k The vaginal wall, on sectional and 
microscopical examination, is found to 
consist of mucous membrane, made up 
of epithelium (the superficial layer being 
squamous and nucleated, the deeper 
layer cylindrical and with elongated 
nuclei), of connective tissue, elastic tissue, and some unstriped 
muscular fibre. The superficial layer of the connective tissue 
forms papillae, into which blood-vessels project. The epithelium 
is therefore rigid. External to this lie two layers of unstriped 
muscular fibre; the inner longitudinal, the outer circular (Henle). 




Fig. 5. — The Vagina, (after re- 
moval of posterior wall). Ou, mea- 
tus urinarius. Oue, external os uteri. 
B, section of wall at the fornix 
vaginae.— (Henle). 



1) Manual of Gynecology, p. 



AX ATOMY OF THE GFXITAL ORGANS. 7 

Breisky alleges the inner to be circular. There are no glands in 
the vagina, but gland-like crypts and lymph-follicles exist | Liowen- 
stein). The whole is surrounded by loose connective tissue, con- 
taining the outer venous plexus of the vagina." 

The vagina is narrowest at the entrance and becomes much 
wider at its upper extremity, where, in women who have borne 
children, it forms a large bag or cavity. The canal is capable of 
extreme dilatation, but when not dilated the walls are in apposi- 
tion antero-posteriorly, except when a true cavity is present in the 
upper part, the walls of which do not close. The bulb of the 
vagina occupies the upper vaginal wall near the entrance, filling 
the space which separates the entrance of the vagina from the 
roots of the clitoris. It is analogous to the corpus urethra. 

The Urethra and Bladder. 

The female urethra is a short, wide canal, less than two 
inches long, directed backward and upward to the neck of the 
bladder. It lies about an inch below the glans clitoridis. and 
immediately above the vaginal entrance, being, as it were, hol- 
lowed out of the upper vaginal wall. Its diameter is about one- 
fourth of an inch, and it is capable of being rapidly distended; 
its mucous coat contains a large amount of elastic tissue. The 
female urethra pierces the triangular ligaments, as in the male. 

The female bladder, when empty, lies behind the pubis and 
in front of the vagina. It is made up principally of two coats. 
mucous and muscular. The only parts of the bladder covered by 
peritoneum are the fundus and a small surface next the uterus. 
Those portions in contact with the pubis and the anterior vaginal 
wall have no serous covering. In the young child and the aged 
woman the longest diameter is the vertical : during adult life the 
transverse diameter is the longest. Its ordinary capacity is about 
one pint : although, when distended, it is capable of holding six 
quarts. The openings into it are three, namely, the two ureters 
and the urethra. These represent a triangular space, of which 
the two ureters constitute the base and the urethra the apex : the 
distance from each opening to the next is about one inch. The 
ureters pierce the bladder obliquely, running for an inch between 
the muscular and mucous coats. 

The urethra may be safely dilated to the extent of admitting 
a slim forefinger to explore the bladder. Dr. Churchill relates a 
case in which the hymen was • • rigid and persistent, the vaginal 
orifice very small, but the urethra extremely dilated, and I ascer- 
tained beyond all doubt, that intercourse always took place 
through the urethra " ill. Dr. H. R. Storer details a remarkable 



Churchill on Diseases of Women, p. S4. 1S57. 



A TEXT-BOOK OF GYNECOLOGY. 




Fig. 6.— A, portio vaginalis ; B, corpus 
uteri; C, fundus; D, Fallopian tubes; E, fim- 
briae ; F, ovaries; G, parovaria; H, round 
ligaments; I, vagina; K, labia majora ; L, 
labia minora; M, clitoris; N, hymen. (Beigel). 



ANATOMY OF THE GENITAL ORGANS. 9 

case, in which a Hodge's open-lever pessary was unintentionally 
introduced into the bladder through the urethra, by a physician. 
Dr. Storer successfully removed it, without incision, by dilating 
the urethra. The patient, a young unmarried woman, soon 
regained complete control of the vesical sphincter. He also refers 
to another similar case. (1) Professor Byford gives details of 
two cases which occurred in his practice, (2) and Dr. Edwards, of 
Lancaster, Ohio, relates the particulars of another, this making an 
aggregate of five cases in which an open lever pessary was intro- 
duced into the bladder instead of into the vagina. 

The Uterus. 

The uterus is the organ which receives the fecundated ovum 
and in which the latter receives the material for its nourishment 
and development. It is a hollow organ, shaped like a flattened 
pear, possessing thick, muscular walls. When unimpregnated it 
is usually about three inches in length, two inches wide at the 
upper part, and one inch thick. It is situated above the vagina 




Fig. 7. — Transverse Section of the Body, showing relations of fundus uteri 
(Savage): M, pubes; A, A, hypogastric arteries in front, spermatic ves- 
ses and nerves behind; B, bladder-, L, L, round ligaments; r, fundus 
uteri; T, T, Fallopian tubes; 0, 0, ovaries; i?, rectum; G, right ureter; 
C, utero-sacral ligaments; V, last lumbar vertebra. 

and between the bladder and rectum. The fundus is uppermost, 
and is directed forward. It is held in position by folds of the 
peritoneum, which is reflected upon its anterior and posterior 
surfaces, being attached to the anterior surface of the uterus at its 
sides, and passing outward and somewhat backward is attached 



1) Gynecological Journal. August, 1870. 
.2; Chicago Medical Examiner, December, 



10 



A TEXT-BOOK OF GYNECOLOGY. 



to the sides of the pelvis in front of the sacro-iliac synchondrosis. 
These are the broad ligaments of the uterus. Their upper border 
is formed mostly by the Fallopian tubes, and that part of the free 
margin not occupied by the tube forms the infundibulo-pelvic lig- 
ament of the ovary. The position of the broad ligaments varies 
according to that of the uterus. When the uterus is normal in 
position, i. e., lying to the front, their posterior surface looks 
upward and somewhat backward, as already described. Dis- 
placement of the uterus backward causes coincident displace- 
ment of the ovaries, and in pregnancy they are drawn up, and 
occupy a position which is almost vertical. Pathologically they 
cicatrize after inflammatory attacks, causing unilateral deviations 
of the uterus. They offer no resistance to anterior or posterior 
displacements, and scarcely any obstacle to prolapsus. 

In addition to the broad ligaments the 
uterus has also the round ligaments and 
the utero-sacral and utero-vesical liga- 
ments. 

The round ligaments are two fibro- 
muscular cords, varying in length from 
four to five inches. They arise from 
the superior angles of the uterus, pass 
forward and outward to the internal 
inguinal canal, and are attached by ten- 
dinous filaments to the substance of the 
mons veneris. On account of the nu- 
merous muscular fibres present, it seems 
probable that their principal use is to 
draw the fundus forward during copu- 
lation, thus lengthening the vagina. If 
they resist displacement at all, it must 
be by preventing retroversion when the 
bladder is enormously distended. 

The utero-sacral ligaments are com- 
posed of peritoneal folds, inclosing smooth muscular fibres. They 
spring from the lower part of the uterine body, and are attached 
to the outer side of the sacrum, leaving a pouch between them, 
called Douglas' sac. These ligaments serve to prevent prolapsus 
and anteversion. In the upright posture the womb naturally leans 
forward, and the utero-sacral ligaments keep it from pressing on 
the bladder. 

The utero-vesical ligaments are only rudimentary. They con- 
sist of peritoneal folds, inclosing fibrous tissues. They extend from 
a point opposite the junction of the body of the uterus with the 
neck, on each side, to the corresponding side of the bladder, form- 




Fig. 8.— Anterior view of Virgin 
Uterus, (Sappey ) : 1, body ; 2, 2, 
angles; 3, cervix; 4, site of os in- 
ternum; 5, vaginal portion of cer- 
vix : 6, external os ; 7, 7, vagina. 



ANATOMY OF THE GENITAL ORGANS. 



11 



ing between them a small anterior pouch. The uterus is also 
closely connected with the bladder, rectum and vagina, and these 
organs aid in maintaining it in position. 

The uterus is divided into a body, or fundus, and a neck, or 
cervix. The upper border, or fundus, is convex, thick, rounded, 
and forms the base of the flattened cone which the uterus repre- 
sents. Clothed with peritoneum and covered with the coils of the 
small intestine, the fundus of the empty uterus never rises to the 
level of the brim of the pelvis ; it is, therefore, only when in a 
diseased condition, or during pregnancy, that it is possible to feel 
it by the fingers applied to the hypogastrium. In the nulliparous 
woman the upper border is nearly straight, and on a level with 
the Fallopian tubes ; after one or more pregnancies it is always 




Fig. 9. — B, median section of virgin uturus; C, transverse section; (Sap- 
pey) : B. 1, 1, profile of the anterior surface; 2, vesicouterine cul-de- 
sac; 3,3, profile of posterior surface; 4, body; 5, neck; 6, isthmus; 
7, cavity of the body; 8, cavity of the cervix; 9, os internum; 10 ; ant. 
lip of os externum; 11, posterior lip; 12, 12, vagina; C. 1, cavity of 
the body; 2, lateral wall; 3, superior wall; 4, 4, cornua; 5, os inter- 
num; 6, cavity of the cervix; 7, arbor vitas; 8, os externum; 9, 9, 
vagina. 

convex, being more raised in the middle than near the origin of 
the tubes. 

The cervix, or inferior extremity of the uterus, forms the 
apex of the cone. The vagina being inserted upon the cervix 
divides it into a vaginal portion and a supra- vaginal portion. The 
vaginal portion is known as the os tincae, and has the form of a 
rounded cone. It usually projects from one-fourth to one-half an 
inch, but may become longer in certain pathological states, and 
gradually disappear as the child-bearing period advances. The 



12 A TEXT-BOOK OF GYNECOLOGY. 

apex of the cervix is pierced by an opening which leads to the 
cavity of the uterus. In the virgin this opening is a transverse 
fissure bordered by two lips, one anterior, the other posterior, the 
anterior lip being thicker and more prominent than the posterior. 
The sensation which the os tincse gives to the finger has been lik- 
ened to that received upon touching the lobule of the nose. At 
the menstrual epoch the neck is a little gaping. In women who 
have borne children the os externum represents a larger fissure, 
often large enough to admit easily the end of the index finger ; 
the lip's are thicker, uneven, and often present notches, the remains 
of the rents they have undergone during labor. One of these 
notches is almost always seen toward the left commissure, a fact 
which is explained by the great relative frequency of the left oc- 
cipitoanterior position. 

Sometimes the portion of the uterus which projects into the 
vagina quite disappears. In such cases the vagina terminates in a 
cul-de-sac, at the bottom of which is felt only a contraction sepa- 
rating the cavity of the vagina from that of the uterus. This 
condition is most frequent in old age. (1). 

The uterus has three openings. There is one at each upper 
angle, leading to the Fallopian tubes, and a third at the lower end 
of the cervix — the os externum — opening into the vagina. This 
has been already described. The openings into the Fallopian 
tubes enter obliquely ; they are only large enough to receive a 
bristle, and are generally filled with mucus. 

The uterine cavity is lined by a thick mucous membrane, 
which is thicker in the cervix than in the corpus. There is no 
submucous tissue between the muscular and mucous layers, so 
that it is practically impossible to separate the two distinctly, 
the muscular fibres and mucous tissue being to some extent inter- 
woven. The peritoneal coat covers the entire posterior surface of 
the womb, dipping down even below the level of the posterior lip ; 
but on the anterior surface it abruptly terminates on a level with 
the internal os, and is reflected upon the bladder. On this account 
the connection between the bladder and the uterus is much more 
intimate than that between the rectum and uterus. A layer of 
cellular tissue binds the neck of the bladder closely to the cervix 
uteri, and any change of position, such as occurs in prolapsus, 
affects the bladder more than it does the rectum. 

Unless when distended by menstrual fluid, clots, tumors, or a 
foetus, the uterine walls are normally in contact. The cavity of 
a virgin uterus is only large enough to contain a split almond. 
The mucous membrane lining the cervix is corrugated, and is 
called ardor vitw. Owing to the presence of the rugae it is some- 

1) Barnes 1 Diseases of Women, p. 42. 



ANATOMY OF THE GENITAL ORGANS. 



13 



times easier to pass a full-sized sound than a very small one, the 
latter being more apt to be caught in a fold, as occasionally hap- 
pens in catheterism of the male urethra. The cavity is slightly 
curved, and therefore the sound should have a corresponding 
curve. 

Uterine mucus has an alkaline reaction. The portion which 
comes from the body is creamy in appearance, while the mucus 




Fig. 10. — Position of Uterus. A, with bladder and rectum empty; B, C, B, 
according to distention of bladder (Van De Warker). 

secreted in the cervix is transparent and viscid, like the white of 



The epithelium of the body, and as far as the middle of the 
neck, is cylindrical, with fine cilia, but the cilia do not appear 
until puberty. The lower third of the neck is lined with pave- 
ment epithelium. 

The weight of the uterus, at puberty, is about one and a half 
ounces ; at the full term of gestation, nearly two pounds ; after 
involution, two ounces ; and in old asfe, one ounce. The uterus 



14 A TEXT-BOOK OF GYNECOLOGY. 

may be present in a merely rudimentary form, or it may be 
entirely absent. 

The uterus is so intimately related to,l and connected with, 
surrounding organs and tissues that its movements are limited to 
these connections, and influenced by the changed conditions of 
these organs. The cervix, being somewhat firmly held in position 
by the bladder and vagina, has a very limited range of motion. 
The fundus uteri, on the other hand possesses very considerable 
mobility, and when thrown backward, or forward acts as a lever, 
throwing the cervix in the opposite direction. When the bladder 
and rectum are empty the uterus lies normally in a position of 
slight anteflexion, but if the bladder becomes distended it will 
force the fundus backward, (Fig. 10) ; or, if the rectum becomes 
loaded, it will be pressed forward and downward. 

' 4 In retroversion of the fundus of the uterus, enlarged by ges- 
tation or other causes, the cervix may be driven so firmly against 
the symphysis pubis as to close the urethra ; and as the base of 
the bladder to which the cervix uteri is attached has a certain 
amount of mobility, in anteversion of the body of the uterus the 
cervix may be carried back close to the promontory of the 
sacrum, dragging the attached wall of the bladder with it. But 
the upward mobility of the part of the bladder to which the cer- 
vix is united is limited ; hence it happens that when the fundus is 
thrown backward, the cervix, held down in some degree by its 
vesical attachments, becomes bent, so that the os looks downward, 
instead of being projected forward exactly in a line with the axis 
of the fundus. 

" In case there is present a collection of blood in Douglas' 
cul-de-sac — retro-uterine hematocele — the whole uterus may be 
driven forward closely behind the pubis. The fundus also is 
prone to a slight lateral displacement. Even in health this is 
commonly present in a slight degree, the uterus being usually 
inclined a little to the left side. 

' ' Some amount of alternate elevation and depression of the 
uterus takes place normally, under the influence of respiration and 
of voluntary muscular exertion. On inspiration the entire mass 
of abdominal viscera is forced downward, pressing the uterus 
before it. On expiration there is a general movement of collapse 
toward the center of the body, under the influence of atmos- 
pheric pressure. This, of course, bears most directly upon the 
external soft parts. The perineum and vulva are pressed inward, 
and the uterus rises toward the abdomen. Under the influence of 
defecation, again, or of any powerful muscular exertion in which 
the chest-walls are fixed, the uterus is driven downward; some- 
times, indeed, so violently that complete prolapsus of the uterus 



ANATOMY OF THE GENITAL OBGANS. 



15 



occurs in a virgin, under the violent efforts of epileptic convul- 
sions. The descent of the uterus, anterior wall of the vagina, 
and base of the bladder, is very obvious, if vomiting or coughing 
occur during an examination by speculum. The instrument is 
easily driven out, as the os uteri is often brought quite down to 
the vulva. This observation proves that the so-called ligaments of 
the uterus exert but a small influence in preventing prolapsus." (1). 
It has long since been settled that while the uterine ligaments, 

G G 5 

the vaginal walls and the perineum contribute to the support of 




Fig. 11. — Diagram 

{Schultze), 



to show Normal Form and Position of Virgin Uterus 



the uterus, they do not by any means constitute its entire support, 
all the segments of the pelvic floor, both pubic and sacral, being 
required for that purpose. Although these supports are slighter 
and more easily overcome than was formerly believed, they are 
supports, and interference with them is an important link in a 
chain of untoward events. The various uterine supports are to a 
great extent the seat of motor influence. They consequently not 
only resist excessive movement, but also serve to return the organ 
from its physiological migrations. 



1) Barnes' Diseases of Women, p. 37. 



16 A TEXT-BOOK OF GYNECOLOGY. 

The Fallopian Tubes. 

The Fallopian tubes are the oviducts, or excretory ducts of 
the ovaries, but, as Dr. Barnes says, (1) " they differ from all 
other excretory ducts in being entirely detached from their proper 
glands," and they furnish the only example in the human body of 
direct communication between a mucous and a serous surface. 
They arise one on each side of the uterus and run out 
from its upper angles toward the sides of the pelvis, where they 
terminate in fringe-like ends, which are known as their fimbriated 
extremities. Only one of these fringes on each side runs to and is 
attached to the ovary, but at certain times the whole fimbriated ex- 
tremity embraces the ovary, and receives an ovum which is to be 
conveyed to the uterus. The Fallopian tubes lie enclosed in the 
upper free margin of the broad ligaments, and vary in length 
from four to six inches, the right tube being frequently longer 
than the left. The uterine end of the tube is known as the 
isthmus, and possesses a canal scarcely large enough to admit a 
bristle. That portion lying between the isthmus and the fimbriae 
is called the ampulla ; it is curved, about one-fourth of an inch in 
diameter, and its canal will admit the extremity of an ordinary 
sound. 

The tube is composed of three coats : an external, or perito- 
neal, a middle, or muscular, and an inner, or mucous coat, the 
latter being lined with ciliated columnar epithelium. Connective 
tissue and elastic fibres lie between the peritoneal and muscular 
layers. No glands exist in the mucous membrane, which is much 
folded in a longitudinal direction, especially in the ampulla. 

The Ovaries. 

The ovaries, two in number, are situated one on either side of 
the uterus, behind the Fallopian tubes, in the posterior fold of the 
broad ligament. They are small, oval-shaped bodies, with a 
smooth surface, about the size of an almond, and weigh about 87 
grains each. At the menstrual periods the ovaries increase in bulk 
and vascularity. At the menopause they present a fissured, lean 
appearance, from the monthly escape of ova, so that they are 
much reduced in size, and in elderly women the weight does not 
often exceed forty grains. 

The ovaries are maintained in position by the broad ligaments 
(which make for them a kind of mesentery), and by a special liga- 
ment, the ligament of the ovary. Their location, however, varies 
according to age and the condition of the uterus. In the foetus 
they are placed, as is the fundus of the uterus, in the lumbar 
region. During pregnancy they rise in the abdomen with the 

1) Op. Cit. 



ANATOMY OF THE GENITAL ORGANS. 



17 



body of the uterus, with the sides of which they are then in con- 
tact. Immediately after delivery they occupy the internal iliac 
fossae, where they sometimes remain throughout life, fixed by acci- 
dental adhesions. Frequently they are found turned backward, 
and adhering to the posterior surface of the uterus. Sometimes 
an ovary is found in the sac of an inguinal, a femoral, or even 
an umbilical hernia. 

The ovarian ligament is about one and one-fifth inches in 
length, and extends from the inner end of the ovary to the corre- 
sponding upper angle of the uterus, just below the uterine origin 
of the Fallopian tube. It is a longitudinal fold of the peritoneum, 




Fig. 12. — Ovary and Fallopian tube: o, d, Fallopian tube; o, ovary; o, a, 
fimbriated extremity of the tube; p, o, parovarium. 

into which the unstriped muscular fibre of the uterus is 
prolonged. 

The ovarian fimbriae prevent the separation of the ovaries and 
the infundibulum tubae. Thus the ovaries are kept in position by 
their attachments to the broad ligament, as well as by the ovarian 
and the infundibulo-pelvic ligaments. Their own specific gravity 
has also a share in determining their position, for the ovaries float 
at a certain level. 

The ovary has an anterior and a posterior border, and an 
upper and lower surface. The posterior border is convex and 
free, the anterior is flattened, and attached to the broad ligament. 
The blood-vessels and nerves enter on the anterior border. 

The ovary is invested with two coverings. The outer coat is 



18 



A TEXT-BOOK OF GYNECOLOGY. 



serous, but its surface differs from serous surfaces generally, in 
that its epithelium is made up of columnar nucleated cells, having 
a dull lustre. It is known as the germ epithelium. The inner 
coat is made up of condensed connective tissue, and is called the 
tunica albuginea. The two coats are so intimately blended that it 
is impossible to separate them. Within its outer investments lies 
the parenchyma of the ovary. The parenchyma is composed of two 




Fig. 13. — Longitudinal section of an ovary from a girl eighteen years old: 
1, Albuginea; 2, fibrous layer of cortical portion; 3, cellular layer of 
cortical portion; 4, medullary substance; 5, loose connective tissue. 

distinct parts, the outer, or cortical, and the inner, or medullary. 
The medullary substance is very vascular, and has some unstriped 
muscular fibre around the branches of the ovarian artery. The 
cortical layer is the most important part of the ovary, as in it the 
ovula are formed. It contains the ovi-sacs, or Graafian vesicles, 
destined to secrete and expel the ovum, and an intermediate struc- 
ture in which these vesicles are scattered, called the stroma. 
According to Barnes the limitation of the ovula to the cortical 
portion is most marked in infancy, and after puberty they are apt 



ANATOMY OF THE GENITAL ORGANS. 



19 



to invade the medullary portion. Hart and Barbour say that they 
"are scattered through the whole substance of the ovary." 

The Graafian follicles are very numerous. It is estimated 
that each ovary contains 36,000. They are at first microscopic, 











10P 



Fig. 14. — Portion of vertical section through ovary of bitch: a, epithelium 
of ovary; 6, 6, tubules of ovary; c, young follicles; d, mature follicles; 
e, discus proligerus, with ovum; f, epithelium of second ovum in same 
follicle; g, tunica fibrosa folliculi; h, tunica propria folliculi; t, mem- 
brana granulosa (Waldeyer). 

but become larger as they mature: The larger follicles lie nearer 
the surface than the smaller ones, having advanced from the 
deeper layer. Each follicle contains an ovum, and at least one is 
discharged at each menstrual nisus. 

As an ovum matures, the Graafian vesicle increases in size, the 
overlying coats of the ovary becoming thinner and thinner, until 
finally rupture occurs, and the ovum is discharged. This is fob 



20 



A TEXT-BOOK OF GYNECOLOGY. 



lowed by the formation of the yellow body, or scar, on the surface 
of the ovary, known as the corpus luteum, and of no importance 

fv 




Fig. 15. — Diagrammatic section of Graafian follicle. 1, Ovum; 2, mem- 
brana granulosa; 3, external membrane of Graafian follicle; 4, its ves- 
sels; 5, ovarian stroma; 6, cavity of Graafian follicle; 7, external cov- 
ering of ovary. 

in gynecology, which never fully matures except when pregnancy 
takes place. The corpus luteum was at one time supposed to be 




Fig. 16. — Diagrammatic representation of the pelvic peritoneum, as seen 
in a mesial section (Ranney): P, P, peritoneum; P, rectum; U, uterus^ 
P, bladder, distended; S, symphysis pubis. 



ANATOMY OF THE GENITAL ORGANS. 21 

positive evidence of previous pregnancy, but this view is no longer 
tenable. Corpora lutea formed after conception takes place are 
larger, and continue longer, than those which result from the 
escape of an unimpregnated ovum. 

In rare cases a woman may have three ovaries. Grohe 
mentions such a case in one who had borne children. It is not 
impossible that ova and ova-sacs may be dispersed in groups 
between the layers of the broad ligaments ; and such anomalies 
may account for the continuance of menstruation after double 
ovariotomy. 




a 
Fig. 17. — Arterial vessels in a uterus ten days after delivery. The posterior 
aspect is shown. 1, fundus uteri; 2, vaginal portion; 3, 3, round liga- 
ment; 4, 4, Fallopian tubes; 5, right ovary; 6, abdom. aorta; 7, inf. mes- 
enteric art.; 8,8, spermatic arteries; 9, common iliac; 11, hypogast. art. 

The Parovarium. 

This is a rudimentary structure, sometimes called the organ 
of Rosennriiller, consisting of a triangular group of small tubules 
situated in that portion of the broad ligament which intervenes 
between the outer end of the ovary and the distal extremity of 
the Fallopian tube. These tubules may vary in number from five 
or six to as many as twenty-five or thirty. They lie in the midst 
of the delicate cellular tissue which exists between the folds of the 
broad ligaments, and have no close attachments to any of the sur- 
rounding parts. Cystic degeneration is liable to occur within and 
around the parovarium, and such pathological possibilities make 



22 



A TEXT-BOOK OF GYNECOLOGY. 



this apparently insignificant organ quite important to the gynecol- 



ogist. 



The Vessels and Nerves. 

It is highly important to obtain an accurate knowledge of the 
vascular and nerve-supply of the female generative organs. 




Fig. 18. — Nerves of the uterus. A, plexus uterinus magnus; B, plexus 
hypogastrics ; C, cervical ganglion. 1, sacrum; 2, rectum; 3, bladder; 
4, uterus; 5, ovary; 6, extremity of Fallopian tube (Frankenhaeuser). 

The blood-vessels going to these parts are very numerous, and 
are derived from various sources. In the first place, the two sper- 
matic arteries run through the broad ligaments to the uterus, and 
supply the ovarian tubes, the ovaries, and the fundus uteri with 
an ample, freely anastomosing, vascular network. Secondly, the 



ANATOMY OF THE GENITAL ORGANS. 



23 



uterine artery, derived from the hypogastric, extends mainly 
through the broad ligament to the point of junction of the body 
of the uterus with the cervix ; frequently, on the left side this 
artery is found to be double. From the hypogastric artery there 
are also derived a number of smaller arteries which supply the 



vagina — the vaginal arteries. 

The blood-vessels of the external genitals come from the com- 
mon pudic artery. Finally, the epigastric artery sends to the 
uterus a branch which goes to the upper uterine angle along with 
the round ligament. 

These various arteries anastomose freely with one another, 
and alongside of them a great number of valveless veins, with 




12 13 



%?bW^% 



jfljj 




1 Tiia 



Fig. 19. — Uterine and utero-ovarian veins (plexus papiniformis). 1, uterus 
seen from the front; its right half is covered by the peritoneum: upon 
the left half may be seen the plexus of utero-ovarian veins (internal 
spermatic); 6, utero-ovarian vessels covered by peritoneum; 7, the same 
vessels exposed; 8, 8, 8, veins from the Fallopian tube; 9, venous plexus 
of the hilum ovarii; 10, uterine vein; 11, uterine artery: 12, venous 
plexus, covering the borders of the uterus; 13, anastomoses of the 
uterine with the utero-ovarian vein (int. spermatic). 

multiple intercommunications, extend to the point of origin of 
thu arteries ; that is to say, the pampiniform plexus extends 
upward to the spermatic; the uterine plexus laterally outward to 
the hypogastric, which also receives the vaginal plexus; and a 
third set extends with the round ligament outward to the abdomi- 
nal coverings. 

In the neighborhood of the veins and arteries, lymph-vessels 
likewise course through the broad ligaments. 

The nerves of the uterus and ovaries are, for the most part, 
derived from the sympathetic, through its lateral hypogastric 
plexus, which is situated within the broad ligaments at the side of 
the uterus. The third and fourth and sacral nerves also send a 
few filaments to the Fallopian tubes and the ovaries. 

Of greater importance than the uterine nerve-supply is a 
knowledge of the pelvic nerves, which are often made to suffer by 



24 A TEXT-BOOK OF GYNECOLOGY. 

pressure, or from being involved in inflammation of surrounding 
structures. Those which are specially liable to suffer in this way 
are the nerves of the lower extremities, springing from the sacral 
plexus. The fourth and fifth lumbar nerves, the sacral nerves 
issuing from the foramina of the sacrum, and the superior coccy- 
geus, together form the sacral plexus. The upper nerves cross 
the innominate line in their course over the wing of the sacrum. 
At this point irritation of the nerves, and consequent neuralgia, 
may be set up by the pressure of an obstetric instrument, by inflam- 
mation in the track of a wound, or by the pressure of a long per- 
sisting exudation. 

The parts of the sacral plexus lying in the pelvic cavity may 
also become irritated, so that not infrequently we observe neural- 
gia and pareses in various regions of the lower extremities in 
consequence of inflammation of the pelvic connective tissue. 



CHAPTER II. 



GENERAL ETIOLOGY OF GYNECOLOGICAL DISEASES. 

Before proceeding to the examination of a patient supposed 
to be suffering from some gynecological disease, it is important 
that we have a proper knowledge of those general causes which 
may predispose to these affections. I do not refer to inherent 
constitutional causes, or to those which are in any way the result 
of accident, but only to those avoidable causes which arise from 
the lack of a proper observance of the laws of health, and which 
are, unfortunately, the basis of many of the diseases we shall be 
called upon to consider. 

The fact that the female is physically inferior to the male is 
not due so much to her natural organization as to the fact that 
the mode of life which modern society forces upon her is unnat- 
ural, and begets physical degeneration. When we study the his- 
tory of the lower animal kingdom we find that the physical 
capacities of the female are at least equal, and in many instances 
superior, to those of the male, and the same rule holds good as we 
approach the lower races of the human species. It is only when 
the deteriorating influences of refined society begin to operate, that 
we find the physical organization of the female depreciating, and 
her powers of endurance, as well as her capacity for resisting dis- 
ease, becoming inferior to those of the male. 

While the physician cannot hope to overcome these condi- 
tions, which, being multiplied in each generation, are becoming 
the inheritance of refined society, yet a knowledge of them may 
enable him to appreciate their influence in an individual case, 
and, by requiring a strict observance of proper hygienic rules, he 
may be able in some degree to overcome their baneful influences. 
I shall mention only the most important predisposing causes of 
gynecological disease, especially those which are essential to diag- 
nosis as well as treatment. Nor is it necessary to spend much 
time in details, for the methods by which these conditions produce 
physical degeneration and consequent tendency to disease are too 
apparent to require lengthy elucidation. 

25 



26 A TEXT-BOOK OF GYNECOLOGY. 

These conditions may be enumerated as follows :— 

1. Lack of fresh air and sunshine; 

2. Lack of exercise; 

3. Over-study and mental strain; 

4. Excessive nervous development; 

5. Improprieties of dress; 

6. Imprudence during menstruation; 

7. Imprudence after parturition; 

8. Prevention of conception; 

9. Induction of abortion. 

Were it possible to induce women of the present day to take 
more exercise in the open air, whether in the way of work or 
recreation, and at the same time to attire themselves in a rational 
manner, discarding those well-known improprieties of dress which, 
though possibly developing grace and beauty, are not conducive 
to health, there would doubtless be less work for the gynecologist 
It is a fact, however, that so far as this class of causes is concerned, 
the greatest harm is done before the age of maturity, and wdiile 
the generative organs, and the nervous system which presides over 
these organs, are in the stage of development. Until puberty the 
girl and the boy develop in the same ratio, but after that time the 
boy develops slowly and almost imperceptibly, while the girl 
experiences a sudden transition, which necessarily involves a great 
strain upon the generative organs, and taxes the nervous system 
to its utmost. Could the girl at this time be entirely subject to 
hygienic rules, and controlled by wise counsel, having only in view 
her future health, this period might be passed in safety. But, 
unfortunately, this is seldom the case. The strain already placed 
upon her system by nature is greatly augmented by the artificial 
life which is now imposed upon her. She at once ceases to be a 
girl, and is taught to look upon herself as a young lady. Her 
time is entirely occupied in hard study, often in acquiring unnec- 
essary accomplishments. The dress which she wore in girlhood 
is changed for whale-bones, corsets, skirts hanging from the hips, 
and high-heeled shoes. Her exercise is obtained at parties and 
balls. She is subject to continual emotional excitement, and if 
she have any spare time it is spent in devouring light and trashy 
literature. Could mothers be induced to appreciate the impor- 
tance of a more rational system of exercise, dress, and education 
for their daughters ; could they only be made to realize that there 
is plenty of time for education and society, and that the dress, 
diet and habits of a girl should not change until at least two or 
three years after puberty, the prevalence of gynecological diseases 
would be greatly diminished. In girls a lack of outdoor exercise, 
over-study, improper dress, imprudent diet, late hours, irregular 



ETIOLOGY OF GYNECOLOGICAL DISEASES. 27 

habits, novel-reading, and similar vices, which usually accompany 
a premature entrance into fashionable society, have much to do 
with laying the foundation for future ill-health and disease. 
Could girls remain girls, and be treated as such until development 
is complete, we would have fewer premature ' ' young ladies, " and 
more strong, healthy women, enjoying life for themselves, and 
transmitting to their offspring the physical basis of a strong con- 
stitution. 

In all ages, during ovarian activity, but especially in the 
young, do the pernicious influences which have been mentioned 
tend to weaken the tone of the nervous system, by giving it an 
unnatural stimulation and excessive development, these being con- 
ducive to the neuralgic diathesis, which constitutes the foundation 
of many of the diseases peculiar to women. Dr. Thomas says 
(1) "that when there is an excessive development of the ner- 
vous system the physiological congestion of the pelvic organs 
attending ovulation produces pain which is known as ' neuralgic 
dysmenorrhea ;' ovulation becomes irregular and abnormal, favor- 
ing the development of subacute ovaritis ; the normal hypertro- 
phy of the uterus consequent upon utero-gestation slowly and 
imperfectly passes off, subinvolution often remaining ; while the 
enfeebled muscular supports of the heavy organ allow it to lapse 
from its position and assume that of flexion or version. ■' 

Imprudence during menstruation might well be classed in 
connection with the causes already mentioned, as more frequently 
occurring under such conditions ; yet, aside from these, it consti- 
tutes a frightful cause of ovarian and uterine disease. Exposure 
to cold or wet, over-exertion, dancing, and other imprudences 
during menstruation, are greatly to be deprecated. 

Another cause of pelvic disease, operating only in those of 
more advanced age, is imprudence after parturition. Especially 
does this occur on getting up and assuming ordinary vocations 
before involution is accomplished. The prevention of conception 
and the induction of abortion, are also equally pernicious. The 
use of the condom or preventive pessary, the use of cold injections 
immediately after intercourse, the withdrawing of the male organ 
before ejaculation, and other similar devices for the purpose of 
preventing conception, while to the ignorant apparently harmless, 
are, for obvious reasons, very deleterious to the female organism, 
and conducive to disease. 

The cause last mentioned is growing to be one of the most 
prolific. The evil of criminal abortion is becoming so startlingly 
frequent in all classes of society that its ultimate consequences 
upon the human race are fearful to contemplate. I do not now speak 

1) Diseases of Women, p. 45. 



28 A TEXT-BOOK OF GYNECOLOGY. 

from the standpoint of the moralist, who sees in it crime without 
parallel in modern society, but I would call attention to the dis- 
ease and misery which it entails. Its unfortunate but too willing 
victims suffer continually from inflammations, diseases of the pel- 
vic viscera, and displacements of the uterus ; they lead lives of suf- 
fering, and die before their time. In closing these remarks I will 
again quote from Dr. Thomas (1), who, in speaking on a similar 
subject, says : " Before any improvement is attained in this or any 
other matter, its importance must be estimated by, and a desire 
for it cultivated in, those whom it most nearly concerns. Neither 
appreciation of, nor desire for, physical excellence sufficiently exists 
among the refined women of our day. Our young women are too 
willing to be delicate, fragile, and incapable of endurance. They 
dread, above all things, the glow and hue of health, the rotundity 
and beauty of muscularity, the comely shape which the great 
masters gave to Venus de Medici and Venus de Milo. All these 
attributes are viewed as coarse and unladylike, and she is regarded 
as most to be envied whose complexion wears the livery of disease, 
whose muscular development is beyond the suspicion of emhon- 
point, and whose waist can almost be spanned by her own hands. 
As a result, how often do we see our matrons dreading the pro- 
cess of child-bearing as if it were an entirely abnormal and de- 
structive one ; fatigued and exhausted by a short walk on their 
ordinary household cares ; choosing houses with special reference 
to freedom from one extra flight of stairs, and commonly debarred 
the great maternal privilege of nourishing their own offspring! 
These are they who furnish employment for the gynecologist, and 
who fill our homes with invalids and sufferers." 



1) Op. Cit. 



CHAPTER III. 

EXAMINATION AND DIAGNOSIS OF GYNECOLOGICAL DISEASES. 
RATIONAL HISTORY. MANUAL EXAMINATION. 

Rational History. — It is not to be assumed that every 
woman who presents herself for examination and treatment, is suf- 
fering with a local disease of the generative organs. There are 
many instances in which disturbance of the ganglionic nervous 
system, due to faulty nutrition and other causes, has produced 
functional disorders of the generative system, and where, espe- 
cially in girls, a physical examination is not warranted until the 
physician by other methods is satisfied that a local disease exists. 
But when an examination has been decided upon, it should be 
pursued systematically, as we would examine a patient suffering 
from any other form of chronic ailment. In conducting it, I 
would impress upon the student the importance of following the 
excellent rules for the examination of patients as laid down by 
Hahnemann (1), rules which arc too much neglected by his fol- 
lowers. Especially should the rule be adopted never to ask a 
question that can be answered by yes or no. Patients of this 
class are, as a rule, imaginative, and a mere suggestion from the 
physician is sufficient to lead them astray. "An unfaithful 
description of the disease would then result, and consequently an 
inappropriate choice of the curative remedy." 

The examination should be taken down in writing. This 
should be in a systematic manner in each case. For this purpose 
it is well to have a record book, wherein, under appropriate head- 
ings, the history of the cases may be preserved with uniformity. 
But the use of such a scheme should not beget the habit of ask- 
ing direct questions, or of interrupting the patient, when detailing 
her symptoms after the general history of the case, i. <?., age, 
occupation, family history, etc., have been recorded. I cannot 
better explain the character of information to be obtained and 
the method of recording it than to give a sample page from the 
record book which I use, the style of which may be changed to 
suit individual ideas. Of course in the case of maidens all ques- 
tions concerning child-bearing, etc., are to be eliminated. 



1) Organon. See. 84, 85, 86, 87, 



30 A TEXT-BOOK OF GYNECOLOGY. 

Case No .... Date Recommended by . . 

Name Residence 

Occupation Single, Married, Widow 

Temperament and appearance 

Family history 



Age.. 



History of general habits and health 
Age at first menstruation 



Married .... years. No. of children .... No. of miscarriages .... 

Criminal ? 

Last labor Miscarriage years since 

Character of last labor, natural, tedious, rapid, instrumental, 

time 

Difficulties afterward 



Has not been well since 

Symptoms during course of disease 



Present condition 



Menstruation, -{ 



Regularity; 

Amount; 

Character; 

Pain at beginning, during, after, flow; 

Character of pain; 

Locality of pain. 



Leucorrheal Dis- 
charges. 



r 



Amount; 
j Color; 
J Consistency; 
| Odor; 
j Acridity. 



Physical examination discloses 



PHYSICAL EXAMINATION. 31 

Physical Examination. — Having obtained a rational his- 
tory of the case, and being satisfied that local disease is present, 
the next step is to make a physical examination. There is often 
considerable difficulty in deciding as to the necessity of this step, 
especially in the unmarried. I cannot too strongly deprecate the 
habit of making local examinations in young and growing maidens, 
until after every other resource has been exhausted. Indeed, 
even in married women, local examinations are becoming too fre- 
quent; but I am convinced that here, as a rule, the fault does not 
lie with the physician. A woman imagines she has local disease, 
and unless the physician makes a physical exploration of the parts 
she is not satisfied, either with him or with his diagnosis and 
treatment, and the chances are that she will call in a physician 
who is more willing to cater to her opinions and desires, even 
though unexpressed in words. A physical examination may be 
either manual, or instrumental. Under no circumstances should 
the instrumental examination precede the manual. Often the 
latter will prove all that is required; at least the information thus 
obtained is essential to a safe instrumental examination, and must 
be the chief guide as to its necessity. 

In order to conduct an examination conveniently and with 
success, it is important, in office practice at least, that the physician 
be provided with some sort of a chair or table designed for this 
purpose. Several kinds of tables have been devised, but these are 
better adapted for operations, and are not suitable for general 
office purposes. Aside from being inconvenient and unsightly, 
they excite more fear on the part of the patient than does an or- 
dinary gynecological chair. Of the latter there have been numer- 
ous patterns invented, each of which probably possesses some 
advantages, but as a rule they have too much machinery, and are 
too complicated to be satisfactory. I am convinced that the nu- 
merous positions in which most of these chairs can be placed by 
the various cranks and ratchets with which they are supplied are 
practically of no value. 

The latest design of chair for gynecological work, and the 
one, in my opinion, best calculated for that purpose, at least for 
the general practitioner, is the "combined office, gynecological 
chair and operating table " recently devised by Sharp & Smith, of 
Chicago. This chair is very simple in its adjustment, is easily 
operated, and when not in use forms a handsome and comfortable 
office chair. Fig. 20 represents the "office" position of the 
chair. Fig. 21 represents the chair turned over from the back. 
It can be so turned with the greatest ease, requiring comparatively 
no exertion. In this cut is also represented an extension which 
is attached to the foot end, thereby making the chair in table form 



32 



A TEXT-BOOK OF GYNECOLOGY. 



sufficiently long for any operation. Fig. 22 represents the chair 
with extension removed from the foot to the right side for ' ' Sims' 
position." Fig. 23 represents the chair in the ordinary gyneco- 




logical position, with stirrup attachments, which can be placed at 
any angle or distance from the foot of the chair.' Under the seat 




will be seen a drawer, which contains all accessories, including the 
extension piece, leaving the chair when not in use as shown in 



MANUAL EXAMINATION. 



33 



Fig. 20. This chair works without cranks, levers or ratchets, 
any position can easily be obtained instantly, and it is movable in 



all directions with but the strength of one finffei 




Fig. 23. 

A convenient ottoman and a leather covered hair pillow 
accompany this chair when desired. 

Manual Examination. —This may be either: 

(1) Abdominal; 

(2) Vaginal; 

(3) Bi-manual — abdominovaginal ; 

(4) Rectal. 



34 A TEXT-BOOK OF GYNECOLOGY. 

(1) Abdominal Examination. — As a rule, it is advisable first 
to examine the external abdomen, though in many instances it 
will be apparent that such an examination is unnecessary. In 
timid patients, a gentle palpation of the abdomen, while perhaps 
unnecessary, leads gradually to the vaginal examination, which is 
most dreaded. At the same time, the patient lying upon her back 
with her knees flexed, the physician can by the use of one or both 
hands determine the locality of any abnormal enlargement or 
tenderness. Should the former be present, he may by inspection, 
palpation, auscultation and percussion decide as to its exact loca- 
tion and character. In connection with a manual examination it 
may be necessary to inspect the external genitals, though this 
should not be a routine practice, and is not to be thought of unless 
there are reasons to believe it necessary. In this manner we may 
discover an absence of hair on the mons veneris, suspicious sores 
or other evidences of specific disease; erosions, eruptions, condy- 
lomata, urethral caruncles, irritable spots causing vaginismus, 
labial abscess, parturition tears of perineum and labia, prolapsed 
pelvic organs, or external or internal hemorrhoids. 

(2) Vaginal Examination. — The vaginal or digital examina- 
tion is the most common of all methods, and is the one usually 
understood when the term u examination " is used. 

This examination may be made as the circumstances of the 
case require, either in the standing, semi-prone or dorsal positions, 
the latter being usually the most desirable, and the one ordinarily 
adopted in this country. In this position the patient is in a better 
shape for an abdominal, bi-manual or instrumental examination, 
should either of these be subsequently deemed necessary. The 
index finger having been carefully smeared with vaseline or soap, 
is gently introduced within the vulva. This is best accomplished 
by placing the back of the hand, the index finger extended, against 
the upper part of the vulva. The point of the finger will then 
rest between the buttocks and against the perineum. By gradu- 
ally raising the hand and pressing backward with the finger the 
latter enters the vaginal orifice, and is then rotated by turning the 
hand into its normal position. If the vaginal orifice is small and 
not easily found, the finger may be drawn upward until it touches 
the smooth vestibule, and then passed backward along the base of 
the vestibule into the vagina. Care should be taken not to enter 
the rectum by mistake, as is sometimes done, notwithstanding 
the resistance of the sphincter ani. 

The vaginal examination reveals the following conditions: 
(1) The presence or absence of the hymen; the presence of 
spasm; the presence at the vulva of a foreign body — polypus or 
malignant growth — or a prolapsed uterus. 



VAGINAL EXAMINATION. 35 

(2) The condition of the vagina as regards temperature, 
smoothness, elasticity, tone and tenderness of its walls; contrac- 
tion of its passage; fistula; foreign bodies, etc. 

(3) The presence of fecal accumulations in the rectum, or 
foreign bodies within the rectum or bladder. 

(4) The shape, density, size, mobility, direction, length and 
sensitiveness of the cervix, and the presence of fissures, indenta- 
tions or excrescences upon its surface. 

(5) The shape, size and consistency of the lips of the os uteri; 
its patency; lacerations; polypi; fungoid excrescences; fragments 
of abortion; cancerous masses, etc. 

(6) Abnormalities in the forniccs. In the posterior fornix 
there may be fecal accumulations; a knuckle or semi-hernial pro- 
trusion of the bowel; a retro verted or retroflexed fundus uteri; 
acute or chronic inflammatory products; hematocele; fibroid tumor 
of posterior uterine wall; cancerous deposits; ovarian cyst or in- 
flammation; ascites; rarely extra uterine fetation. In the ante- 
rior fornix: — anteverted or anteflexed fundus uteri; inflammatory 
deposits and cellular exudations; fibroid of anterior wall; blood 
effusion; prolapsed ovary, etc. All these conditions are rare in 
the anterior fornix unless it be the first named. 

In the lateral fornices may be found: continuations of lymph 
or blood exudates as found posteriorly or anteriorly; lateral ute- 
rine displacement; lateral fibroids; prolapsed or cystic ovary ; dila- 
tation of Fallopian tubes. 

(3) Bi-Manual Examination. — Of late years the bi-manual 
examination is being recognized as the most important of all 
methods of diagnosis, and it is usually considered that no exam- 
ination is complete or approximately correct without it. It con- 
sists in introducing one or more fingers of the right hand into the 
vagina, while the other is placed upon the abdomen about midway 
between the umbilicus and pubes, and the fingers made to press in 
the direction of the axis of the pelvic inlet. Thus, while with 
one hand the pelvic cavity is explored, with the other hand not 
only are the contents of the pelvic cavity brought within its reach, 
but the fingers can be slowly and gently pressed downward from 
above the brim and made to meet those in the vagina, unless a 
normal or abnormal substance intervene. In this way the size 
and relations of the pelvic contents are estimated, and any abnor 
mal exudations or growths are detected and defined with compara- 
tive certainty. 

The bi-manual method is always available except when car- 
cinoma or acute inflammation is present. It is most difficult of 
performance in stout multiparous women, and in cases of pelvic 
inflammation, and occasionally under such circumstances an anses- 



36 



A TEXT- BO OK OF GYNECOLOGY. 



thetic is required, or the reetal method of examination may be 
substituted. 

It is desirable that the practitioner persistently practice this 
method of examination in order that it may become familiar to 
him, as it constitutes the most satisfactory and accurate method of 
pelvic diagnosis. Closely associated with the bi-manual or abdo- 




Fig. 24. — Bi-Manual Examination. The upper hand is not shown (Hart). 

mino-vaginal method are other bi-manual methods, which. peculiar 
circumstances and conditions sometimes require. These are : 

1. Recto-abdominal (finger in rectum and left hand 
above) ; 

2. Recto- vagino-abdominal (middle finger in rectum, 
index finger in vagina, and left hand above); 

3. Vesico-vagino-abdominal (middle finger in vagina, 
index finger in bladder, and hand above). 

4. Vesico-rectal (index finger of one hand in bladder, 
index finger of other hand in rectum). 

(4) Rectal Examination. — In some cases it becomes neces- 
sary to examine the pelvic organs by introducing the finger, well 
oiled, into the rectum. The method is repugnant alike to patient 
and physician, and the knowledge obtained is necessarily limited 
and obscure, especially in comparison with the results of a bi- 
manual examination. For these reasons it should never be resorted 
to, except where circumstances make it necessary. There may be 



VAGINAL EXAMINA TION. 



37 



cases, especially in young 



s, in which a vaginal examination 
should be avoided, or where, for other reasons, the vaginal and 
bi-manual methods cannot be employed; then the examination may 
be made per rectum. In cases where there is obstruction of the 
genital passages, or where in virgins we suspect hematocele or re- 
troversion, the rectal examination is valuable. Prolapsed ovaries 
are more easily detected by this method, and it is the only one 
available for the diagnosis of internal hemorrhoids, rectal polypi, 
fissures, ulcers, strictures and cancerous growths within the rectum. 
In making the rectal examination by simultaneously compressing 




Fig. 25.— Anterior Abdominal Surface of Female, with upper hand 



placed for Bi-manual. 



hand we have the 
which is the most 



recto-abdominal 
valuable of the 



the abdomen with the other 
method already referred to. 
various rectal methods. 

I will merely mention Simon's method of rectal examination, 
which consists of passing the whole hand into the rectum even up 
to the transverse colon, the patient being anaesthetized. While 
this method doubtless offers satisfactory diagnostic results, it 
nevertheless involves great danger of injury to the patient, even 
to rupture of the peritoneum in the left flank, and thus the good 
results are more than counterbalanced. As one author says, ' ' an 



38 A TEXT-BOOK OF GYNECOLOGY. 

accurate diagnosis may be purchased too dearly, and an approxi- 
mate one may be preferable, if it is more consistent with the re- 
covery of the patient." A careful bi-manual examination, aided 
when necessary by an anaesthetic, will give equally satisfactory 
results. 

I consider Simon's method as an unjustifiable procedure, and 
believe it cannot be too severely condemned. 



! 



CHAPTER IV. 



. INSTRUMENTAL EXAMINATION. 

Manual examination having proved insufficient for diag- 
nostic purposes, we may resort to an exploration of the parts by 
the use of instruments. In conducting such an examination the 
instruments chiefly used, either singly or conjointly, are: 

(1) The vaginal speculum; (2) the uterine sound or probe; 
(3) cervical dilators; (4) the curette; (5) the aspirator. 

(1) The Vaginal Speculum. — A great variety of vaginal 
specula have been invented, most of which have their peculiar ad- 
vantages, but for practical purposes it is necessary to describe but 
three typical varieties: 

1. The cylindrical, or Fergusson speculum; 

2. The bi-valve; 

3. The duck-bill, or Sims' speculum. 

1. The Cylindrical, or Fergusson Speculum. — Cylin- 
drical specula are made of various materials, but the Fergusson 
speculum, which is unquestionably the best, consists of a simple 




Fig. 26. — Fergusson Speculum. 



glass tube made of various sizes, coated with reflecting mercury, 
and covered with caoutchouc. The proximal end is trumpet- 
shaped and the distal end beveled, so that its anterior side is 
shorter than the posterior. It is usually introduced with the 
patient in the dorsal position, but is equally useful in the semi- 
prone position. The speculum, previously anointed with oil or 
vaseline, is pressed against the perineum, along which it is gently 
insinuated until the beveled edge is entirely "within the vagina, 
when it can be readily pushed up to the cervix, though it is often 
difficult to engage that organ in its lumen. The objections to this 
speculum are, that it is sometimes difficult of introduction, its 
field of vision is limited, and it is very fragile. Its special advant- 

39 



40 



A TEXT- BO OK OF GYNECOLOGY. 



ages lie in its illuminating power, and that it is readily cleansed, 
and is not damaged by the action of acids and other corrosive sub- 
stances, which often ruin a metal speculum. For diagnostic pur- 
poses the cylindrical speculum is of little value, but it is very 
convenient in making local applications to the vagina or external os. 
2. The Bi- Valve. — A multitude of valvular specula have 
been invented, constructed with two, three, four or more blades. 
Those with three or more blades, such as Nott's and Nelson's, are 




Fig. 28.— Nott's Speculum. 

very little used, and possess no advantages over those with two 
blades, while the fact that the lax vaginal walls may drop between 
the anterior blades and obstruct the vision is a serious disadvant- 
age. Of the many bi-valve specula Cusco's or Miller's are the 
simplest, and are equally efficient as those of more complex 
construction. Hale's, Jackson's and Graves' are base-expanding 
specula, and are very popular instruments. The two former 
dilate by screw power, and are probably the best of this class. 
Graves' speculum is expanded by means of a thumb and finger 
pressure that I have found awkward to manipulate. This speculum 
may also be converted into a Sims', but it makes a poor Sims', 
and when we consider the great reduction that has been made 
in the price of these instruments within the past few years, and 
the low figures at which they can be purchased, it is hardly ad- 
visable to sacrifice a ^ood bi-valve speculum for the sake of obtain- 



INS TR U ME NT A L EXAM IN A TION 



41 



ing the advantage of an unsatisfactory Sims'. Graves' speculum, 
as a simple bi-valve. answers its purpose well enough, but as a 
base expander or a Sims 1 it is a failure in both instances. 




Fig. 29. — Cusco's Speculum. 



Fig. 30.— Miller's Speculum. 




Fig 31. — Hale's Speculum. 

A bi-valve speculum is introduced with the blades closed and 
corresponding in direction with the vaginal fissure; it is then 
turned until the blades assume an antero-posterior position, when 
it is pushed upward to near the cervix; here the blades are ex- 



42 



A TEXT-BOOK OF GYNECOLOGY. 



pandecl and held open by means of a screw. The cervix usually 
engages in the lumen, but if not it can be made to do so by 
slightly turning the instrument from right to left, or by slightly 
withdrawing and again pushing it into position. Bi-valve specula 




Fig. 32. — Jackson's Speculum. 



Fig. 33. — Graves 1 Speculum. 



possess the advantage over cylindrical specula in being more easily 
introduced, self-retaining, afford a wider field of vision, and permit 
a freer use of the sound or other instrument. 




Fig. 34. — Sims' Speculum. 

3. The Duck-Bill, or Sims' Speculum. — This speculum is 
the only one we have that in any degree approximates perfection, 
and should be the only speculum used in gynecological practice; 
though, unfortunately, not being self-retaining, it is comparatively 
little used by the general practitioner. Sims' speculum, which 
is represented in Fig. 34, is simply a perineal retractor, and by 
the aid of a depressor it becomes in reality a bi-valve without the 
disadvantages and more complicated mechanism of the latter. It 
can be used only in the left lateral or semi-prone position, familiarly 
known as Sims' position. It is introduced by the patient's being 
placed on the left side, the left arm under and behind her, the legs 



INSTRUMENTAL EXAMINATION 



43 



strongly flexed upon the thighs, and these again upon the abdomen, 
while the right knee is thrown forward and over the left knee on 
the table; this turns the patient over on the chest and partly on the 
abdomen. In this position the speculum is introduced by placing 
the forefinger of the right hand in the concavity of the blade to be 
used, and the finger and instrument introduced together. When 





Fig. 35. — Sims' Depressor 



well inserted, the perineum is drawn backward and the instrument 
given to an assistant to retain in place. 

In the use of Sims' speculum the all-important thing is the 
position of the patient, and unless that be properly attained the 
examination will not be successful. If after the speculum is in- 
troduced the parts are not sufficiently exposed, Sims' depressor 




Fig. 36. — Simon's Speculum. 

may be placed upon the anterior wall, which is thus held out of 
the way. 

Bozeman's modification of Sims' speculum is heavier than the 
original, has the blades meeting the handle at an acute ansrle, and 



44 



A TEXT-BOOK OF GYNECOLOGY. 



the blades more concave on the anterior aspect. Battey's modifica- 
tion has one short blade, which meets the handle at a more 
acute angle than Bozeman's. Simon's speculum is considered by 




Fig. 37.— Simon's Retractor or Plate. 



Schroeder, Fritsch and other distinguished gynecologists as a mate- 
rial improvement on Sims' speculum. This instrument can also 
be used in the dorsal position. The blades are formed exactly 
after those of Sims', but are movable on a handle, so that they 




Fig. 38.— Simon's Flat Steel Hook. 

may be changed according to the size of the genitals. 

Simon also devised a peculiar retractor or plate, with 

which to support the anterior vaginal wall, and flat 

steel hooks to separate the lateral vaginal walls. 

This speculum is not so often used for diagnostic 

purposes, but for operations, especially in Europe, according to 

Fritsch, it is " in universal use. " 

Porter's speculum or perineal retractor differs from Simon's 
speculum mostly in the fact that the handle is placed at an obtuse 
angle, and by having a flange which assists in holding up the over- 
hanging buttock. The position of the handle admits of the instru- 
ment being used with the patient on the back or side, and does 
not necessarily require an assistant. The instrument is made in 



INSTRUMENTAL EXAMINATION. 



45 



four sizes, the smaller blade being adapted to operations about the 
rectum or virgin vagina. 

One of the best modifications of Sims' is that devised bv A.Reeves 




Fig. 38£.— Porter's Speculum. 

Jackson. This instrument is preferred by many because of its sim- 
plicity, its very short and flat blade, and the 
convenient shape of the handle. Besides serving 
as a speculum it makes an excellent retractor. 

Owing to the fact that Sims' speculum, as 
well as other modifications already mentioned, are 
not self -retaining, thus requiring an assistant, 
they have not come into general use. To over- 
come this objection a number of modifications 
of Sims' speculum have been invented, but the 
self-retaining apparatus is usually so compli- 
cated that they have not proved satisfactory. 
Of these I w T ill mention Emmett's perineal 
retractor (Fig. 40), Hunter s modified Erich 
(Fig. 41), Dawson's modification of Sims' (Fig. 
42), and one that I like much better than either 
of these, which is Thomas' again modified by 
Dr. Mann of Buffalo (Fig. 43). The latter 
consists of a Sims' blade w T ith an attached 
depressor so articulated to the blade as not to 
interfere in any way with the field of vision or with instrumental 
manipulation, and — a most important point — so as not to distend 
in the least the ostium vaginae. A hook is also placed on the 
depressor shaft to which a tenaculum, used to draw down or 
steady the uterus, may be attached. Dr. Grandin has recently 
added some modifications to the Mann speculum, which I have 
not seen, which he describes as follows (1): "The instrument is 
altered by adapting the depressor to the lower surface of the blade 
fitting a flange to hold up the superior buttock to the upper sur- 
face of the blade, and by shortening the depressor bar." Dr. 
Grandin says, "This instrument may be held by the left hand, or 




Fig. 39.— Jackson's Mo- 
dified Sims' Speculum. 



1) American System Gynecology. Vol. I. p. 312. 



46 



A TEXT BOOK OF GYNECOLOGY. 



else, when the depressor handle has been screwed down and the 
handle of the instrument removed, we have a self -retaining specu- 
lum, and both hands are free. I have tested this instrument faith- 
fully, and am able with it to perform in 
Sims' position, unassisted, any manipula- 
tion (applications to endometrium, curet- 
ting, etc.,) proper to office practice." It 
would seem that with such an excellent 
instrument as this, it ought not to be nec- 
essary to so frequently resort to the cylin- 
drical or bi-valve specula for diagnostic 
purposes, though after the diagnosis is 
made they may do very well for ordinary 
- local treatments. 
tractor. The chief advantage of the Sims specu- 

lum is that in connection with the semi-prone position which 





Fig. 41.— Hunter's Modified Erich Speculum. 

allows the abdominal viscera to fall away from the back and pelvis 
by their own weight, the vaginal walls are separated, thus allow- 




Fig. 42.— Dawson's Modified Sims' Speculum. 



ing the air to 



nter which distends the vagina, making an open 
cavity, and allowing a full inspection of its contents, and a free 



INS TR UMENTA L EXAMINA TION. 



47 



manipulation of instruments. Abnormal conditions, especially a 
lacerated cervix with ectropium, are neither distorted nor modified, 
this not being the case with any other speculum. For gynecolo- 
gical operations Sims' speculum either original or modified is the 




Fig. 43.— Mann's Modified Thomas' Speculum. 

onlv one that can be used with any degree of convenience or 
success. 

4. The Uterine Sound. — For gynecological diagnosis the 
uterine sound constitutes, all things considered, the most impor- 
tant instrument. The form devised by Simpson is the best, and 




Fig. 44. — Simpson's Uterine Sound. 

the one in general use. It consists of a nickel-plated copper rod, 
twelve inches in length, made flexible so that it may be curved to 
correspond with the shape or curvature of the uterine cavity, yet 
sufficiently firm to admit of its being used as an elevator in uterine 
displacement. It is provided with a suitable handle, which is 
roughened on the side corresponding with the direction towards 
which the instrument is curved, so that the direction of the latter 
is known by the position of the handle. Two and one-half inches 
from the point is a knob which marks the depth of the normal 
uterus. Below this knob the sound is graduated in inches so that 
the operator is constantly informed of the progress the instrument 
is making. On account of the thickness of Simpson's sound it is 
not adapted for use where there exists sharp flexion, stenosis of 
the cervix, etc. For this reason there have been devised several 



48 A TEXT-BOOK OF GYNECOLOGY. 

modifications, which will be noticed later. While the sound may 
reveal important diagnostic indications, and no examination can 
be considered complete without it, yet its injudicious use may re- 
sult in serious injury. Fortunately those conditions where the 
passage of the sound may prove injurious are so well understood 
that with ordinary judgment and care no danger need be appre- 
hended. The sound should never be introduced: 

(1) During a menstrual period; 

(2) During pregnancy; 

(3) During the presence of an acute attack of pelvic 
inflammation, either ovarian, uterine, peritoneal or 
cellular. 

The introduction of the sound should always be preceded by 
a careful bi-manual examination for the purpose of eliminating the 
above contra-indications for its use, and to ascertain the position 
of the uterus. 

The sound may be introduced in either the dorsal or semi- 
prone positions, and with or without the aid of a speculum. Both 
are a matter of habit. I think as a rule it is more satisfactory to 
have the patient in the dorsal position, and that the use of the spe- 
culum is only an unnecessary hindrance. 

Method of Introduction. — With the patient lying on her 
back, the operator places the index finger of the right hand on the 
lower lip of the os uteri to serve as a guide. Then lightly hold- 
ing the sound in the fingers of the left hand, its concavity upward, 
it having already been curved to correspond with the supposed 
curvature of the uterus, its point is carried along the guiding finger 
until it reaches and penetrates the external os. It is then passed 
onward about an inch farther where it will usually meet with an 
obstruction. This may only be the normal internal os, and be 
easily overcome by a slight tilting backward of the handle and 
careful steady pressure, no actual force being exerted. The same 
care and gentleness should be exercised that is employed in intro- 
ducing a catheter. It must be remembered that at this point the 
direction of the uterine canal changes, and that a corresponding 
change must be given to the point of the sound, which is done by 
depressing the handle. As the sound passes on, its progress is 
carefully noted until the knob Avhich marks the normal uterine 
depth has reached the external os. If the point of the sound is 
then at the fundus a slight resistance will be felt, and unless it 
is handled with extreme gentleness the patient will complain of 
pain. If at any time the sound fails to pass easily it must be with- 
drawn, and reintroduced with the curvature slightly changed ac- 
cording to the supposed position of the uterus. Owing to the 
danger of perforating the uterine walls no force whatever should 



INS TR UMENTAL EXAMINA TIOX, 



49 



be used. Perforation is liable to occur especially when the uterus 
has been softened by disease. In case flexion is present, the sound 
must be curved to correspond, and after its point reaches the in- 
ternal os, the handle must be depressed, elevated or rotated, ac- 
cording to the direction given it by the uterine canal. The method 
of introducing and using the sound in flexion and other patholo- 
gical states is more fully considered under their respective heads. 

For purposes of diagnosis the sound informs us as to the 
patency and size of the external os and of the cervical canal, and 
their condition as regards smoothness or roughness of the lining 
membrane. It does give a knowledge of the sensitiveness and 
patency of the internal os; the degree of flexion; the depth of the 
uterus; the sensitiveness of the endometrium; the mobility of the 
uterus; the exact position of the fundus; and the general direction 
of the uterine axis. 

This information ma}' in some instances be made clearer by 
combined manipulation. The sound having been introduced to 
the fundus and held with the right hand, the left hand is placed 
upon and made to depress the abdomen, as in bi-manual examina- 
tion, and this pressure is communicated through the sound to the 
hand which is holding it. 

As to the modifications of Simpson's sound, I will mention 
but a few ; notably that of Thomas, which is a probe made of 



Fig. 45. — Thomas' Uterine Sound. 

whalebone, is flexible, and is especially designed for measuring 
the depth of a tortuous uterine canal, made so by a fibrous tumor. 
Fitch's sound is especially valuable for obtaining accurate measure- 




Fig. 46.— Fitch's Uterine Sound. 




Fig. 47.— Sims' Uterine Sound. 



ment. 81111$' sound is not graduated and is more flexible than 
Simpson's, being more of the nature of a probe, and especially 
adapted to use with Sims' speculum in the semi-prone position. 



50 A TEXT-BOOK OF GYNECOLOGY. 

Jenks' spiral sound is, according to Emmett, an invaluable instru- 
ment, under certain circumstances, for ascertaining accurately the 
depth of the uterine canal. Dr. Emmett and other distinguished 
gynecologists seldom use Simpson's sound, preferring simply a 




Fig. 48. — Jenks' Spiral Uterine Sound. 

surgeon's long silver probe set in a handle. For the use of the 
general practitioner the probe is not usually satisfactory, as it con- 
forms too readily to any abnormal position of the uterus, and often 
misleads one who is not thoroughly accustomed to its use. 

5. Cervical Dilators. — In order to explore the uterine 
cavity it usually becomes necessary to dilate the cervical canal. 
For this purpose there are four classes of instruments: (1) Tents; 
(2) Dilatable tubes of soft rubber; (3) Graduated hard rubber or 
metal dilators; (4) Expanding steel dilators. 

1. Tents. —These are slightly tapering or pencil-shaped 
instruments of different sizes and lengths, prepared from materials 
having the power of absorbing moisture from the surrounding- 
parts, causing them to expand, thus dilating the cervical canal. 
They are constructed either of compressed sponge, laminaria, 
tupelo, or of compressed slippery elm bark. Medium and large 
tents should be perforated lengthwise, except at their apex, thus 
adding to their power and rapidity of expansion, and facilitating 
their introduction by means of a probe or applicator. They should 
also have a strong thread well attached for the purpose of assisting 
in their removal. Tents are usually straight, but can be made 
with any degree of curvature that may be required. 

Sponge tents are usually impregnated w T ith carbolic acid or 
some other antiseptic. They dilate more rapidly than the other 
varieties, but are less powerful in their dilating influence. Sponge 
tents are very objectionable, for the reason that in dilating they 
cause a rough, ragged appearance of the cervical canal, and more 
or less impair its epithelial covering, sometimes setting up an 
inflammatory action that is usually of a septic character, notwith- 
standing all antiseptic precautions. For this reason they are 
gradually being displaced by the tupelo and slippery elm for 
exploring purposes. Laminaria tents are not very popular for 
diagnosis, as they possess feeble dilating power, and their dilation 
does not take place sufficiently at the internal os, where it is most 
desired. 

The tupelo (root of the nyssd aquatica) is quite popular. Dr. 



i 



INSTRUMENTAL EXAMINATION. 



51 



Grandin (1) says "it is the agent par excellence in tent form for 
dilating purposes. Its expansibility is nearly equal to that of the 
sponge ; it dilates equably throughout its length ; it does not 
abrade the cervical tissues to the extent that the sponge does ; it 
is exceptional for its proper use to be followed by sepsis." Ac- 
cording to Hart and Barbour, the special advantage of tupelo tents 
is due to their smaller size and the fact that several may be passed 
into the same cervix. They are specially useful, therefore, in 



1 


r • 




t \ 


1 

1 


; 'If 
i i - | |i 


1 ! ' 
1 ■ i 

a ' 


1 


j i(: 


I ' * 

II I ! 


1 

1 
1 


1 i : i '• 1 

1 ' ' 1 * ' 


i 

i 


1 ! 1 II ' ! 

! 1 


i 


i ] 


M > 

1 i 




1 ! 

j 1 


1 i 




i j 

i 


ill i 

I • i 

1 > ! 

: I j i . i | 




■ < 

! | 

| 

i ' ' 


1 ' ' 

1 1 ' '■ 

1 ' j 

i If 1 


i 
i 


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j i 




Ill ' ' 
1--' \ 



Fig. 49. — Diagram to show relations between size of Tupelo Tent, before 
and after expansion. The dotted outside line indicates the size of the 
tent after expansion (Munde). 

cases of narrow cervix and flexions. The accompanying cut (Fig. 
49) represents their power of expansion. 

For the past two years I have used chiefly the tents made 
from compressed slippery elm bark (Fig. 50). These tents 
possess a less powerful but more rapid expansion than the tupelo. 
They will usually dilate to twice their diameter in one or two 
hours, at which time a larger one, or several more of the same 
size, can be introduced with perfect safety, as they exude a slip- 
pery substance which not only serves as a natural lubricant, but 
also protects the mucous membrane from injury. It may be said 



1) Op. Cit.. p. 321. 



52 A TEXT-BOOK OF GYNECOLOGY. 

of elm tents that they never set up inflammation, which is a very 
important consideration. 

Tents are used not only to dilate the cervix for diagnostic and 
operative purposes, but they are also employed to tampon the cer- 
vix in case of hemorrhage, especially after abortion, and are occa- 
sionally used to correct flexions of the uterus and overcome 
stenosis of the cervix. 

Hollow elm tents kk are also available as applicators, for the 




Fig. 50.— Slippery Elm Tents. 

exuding slime carries the drug out from them instead of into them, 
and gradually dilutes it, thus limiting its action." 

Tents are most conveniently introduced while the patient is 
in the semi-prone position. The cervix, being exposed by Sims' 
speculum, is slightly drawn down and carefully steadied by a vol- 
sellum or tenaculum and the tent introduced by means of a tent 
applicator (Fig. 51) or a pair of dressing-forceps. It should be 




Fig. 51. — Tent Applicator. 



passed, if possible, nearly up to its full length, just projecting 
beyond the os externum. If the applicator is used while the wire 
is being withdrawn the sheath should be pressed against the tent 
in order to keep it in place. The tent is then kept in place by 
means of a suitable carbolized cotton tampon, and the patient 
should, if possible, remain quietly in bed. The largest-sized tent 
should be used that can be introduced without force. If after 
about twelve hours the cervix is not sufficiently dilated, the vagina 
and cervical cavity may be thoroughly cleansed with carbolized 
water, and a second tent, sufficiently large to fill up the partially- 
dilated canal, introduced in the same manner as the first. Espe- 
cially in using sponge tents must the strictest cleanliness be observ- 
ed, on account of the danger of septicaemia. Notwithstanding the 
apparent simplicity and harmlessness of tents, the danger in using 



INS TR UMEN TA L EXAMINA T10N. 



53 



them should not be underestimated, nor any precautions neglected 
that will insure safety. 

2. Dilatable Tubes of Soft Rubber. — The typical instru- 




Fig. 52.— Molesworth Uterine Dilator 

merits of this variety are Molesworth's dilators (Fig. 52), and 
Emmett's water dilator (Fig. 53). The former is the most avail- 
able instrument for general use. These dilators arc safer than 




Fig. 53. — Emmett's Water Dilator 




Fig. 54. — Allen's Surgical Pumj. 



54 A TEXT-BOOK OF GYNECOLOGY. 

tents from a septic standpoint, and will effect greater dilation, but 
they possess one serious disadvantage common to all instruments 
composed of soft rubber, and that is that they are liable to prove 
inefficient just at the time when most needed. Then, too, they 
cannot be relied upon to stand a continuous strain without bursting. 
Allen's surgical pump (Fig. 54), which is described more fully 
in this chapter as an aspirator, is supplied with attachments that 
overcome all the objections above mentioned. This intrument 
possesses no piston, valve or stop-cock, and there is consequently 
but little liability of its failure to work at all times. The rubber 
bags used as dilators are inexpensive, can be purchased by the 
dozen, and may be prevented from bursting by enclosing in silk 
sacks, which accompany the instrument, or can be quickly made at 
home. These sacks, by confining the expansion of the tube within 
prescribed limits, concentrate the force at such points as offer 
resistance, or tend to prevent the dilating of the tube to the full 
size and shape of the sack. The instrument can thus be made 
much more powerful than the Barnes and other dilators of this 
class, can be introduced much easier, and, as it dilates equally in 
all directions, it is much more to be preferred than any of the 
metal instruments. It accomplishes its results with less tendency 
to inflammation than most other dilators, and with it there is little 
danger of laceration. Fig. 55 shows a few of the shapes most 




Fig. 55. 



commonly used in general work. Fig. 56 shows the form the 
tube will take if not enclosed in a cover, while Fig. 55 shows what 
may be accomplished with them. 

This novel instrument also serves as an aspirator, urethral 
dilator, syringe, douche, tampon and breast pump, and thus be- 
comes of exceptional value to the gynecologist. 

Fig. 5 6 -J- shows the instrument used as a tampon with two 
bags attached, for the purpose of accurately measuring the amount 
of dilatation produced. One bag is first attached and expanded to 
the size desired. Then, the bag to be used on the operation is 



INS TR U MENTAL EXAM IN A Tl ON. 



55 



attached to the other end of the instrument, and, after being intro- 
duced, the current is reversed, and the contents of the first bag 
are forced into it. The amount of dilatation can also be measured 




Fig. 56. 

by counting the number of revolutions, each revolution giving a 
definite amount of expansion. 




Fig. 56|.— Allen's Surgical Pump attached to chair for convenience in bed- 
side work. 

3. Graduated Hard Rubber or Metal Dilators. — Tail's 
(Fig. 57) and Hank's (Fig. 58) are the typical varieties of hard 
rubber dilators. Tait's dilators consist of graduated vulcanite 
cones which can be screwed into a suitable handle. The proximal 
end of the handle is perforated for elastic bands, which, passing in 
front and behind, are attached to a suitable belt round the patient's 



56 



A TEXT-BOOK OF GYNECOLOGY. 



waist. Thus the elasticity of the india rubber causes the cone 
gradually to pass up into the cervix, dilating it as it goes. Tait 
claims that with this dilator he can dilate rapidly and without dan- 
ger of septic infection. Hank's dilators are of very simple con- 




Fig. 5?.— Tairs Uterine Dilat< 




Fig. 58.— Hauk's Uterine Dilator, 
struction, but their action is tedious. The smallest size may be 
passed into the cervix by slow and gradually-increasing pressure. 
It may be succeeded by the second, and that by the third, and so 
on until the cavity will admit the finger. 

Graduated steel sounds (Fig. 59) have for some time been 




Fig. 59.— Graduated Steel Sounds 



recognized as an effective and safe means of dilatation. The atten- 
tion of the profession has recently been called to their value by 






INSTRUMENTAL EXAMINATION. 57 

Dr. E. H. Pratt. He gives the following directions for their 
use (1) : — 

4w The treatment is to be given with the uterus in situ, and 
hence a good bi-valve speculum is indispensable. 

* ' After its introduction, carefully insert a tenaculum a short 
way up the cervical canal, so as to steady it in its place, leaving no 
room for guess-work as to where the work is being done. An 
ordinary flexible uterine sound should now be inserted through the 
entire length of the uterine cavity in order to ascertain its direction 
and extent. 

"The graded sounds should now be introduced one by one, 
beginning with the smallest that will pass with ease until some 
resistance is felt at the internal os. when the work must proceed 
with more care. Never use a uterine dilator of any sort that does 
not exercise an even pressure over the whole circumference of the 
canal, as otherwise individual spots will be more or less bruised, 
and in many instances an otherwise good piece of work will be 
spoiled by the local irritation needlessly set up in this manner. 

"In this way persevere with still larger sounds, even though 
they may have to be crowded slightly to effect their introduction ; 
no harm can result, since they are symmetrical and open the uterus 
after nature's own plan by an even dilatation. When a sound 
passes the internal os a little snugly, as through a rubber ring, and 
passes along the uterine cavity with more ease after it is past the 
point, no matter what the size of the sound may be, the work is 
still not sufficiently thorough. The os is still too irritable, and 
when the instruments are withdrawn it will grip tightly and con- 
line the discharges that must follow the touching of the uterine 
mucous membrane, and as a result there will be liable to follow 
more or less congestion, and perhaps inflammation. 

" Persevere with the sounds, therefore, until the uterus is 
converted into a straight tube, the last one meeting no more resist- 
ance at the internal os than throughout the entire length of the 
uterine cavity. Go no farther than this, for beyond this point a 
rupture of uterine tissue is liable to occur, and your work will be 
overdone, as unnecessary a misfortune as to leave it underdone. 
In either case failure will ensue, whereas by observing this rule 
success is a certainty. This method is a great satisfaction, for it 
takes the matter entirely outside of the pale of guesswork, and 
makes one certain of doing the right thing every time, by every 
uterus from the atrophied organ of sterility, to the overgrown one 
of subinvolution." 

(6 ) Expanding Steel Dilators. — These are the best instru- 
ments to employ for rapid dilation, if we except the Allen Surgi- 



1» Medical Era, Dec. 1886, p. 171. 



58 



A TEXT-BOOK OF GYNECOLOGY. 



eal Pump, which as a dilator has already been described. They 
consist of two or more steel blades expanded by means of screw 
or lever handles. There is a variety of patterns, each of which 
has probably some peculiar advantage. Goodell's modification of 
Ellinger's dilator (Fig. 60) is as good as, and perhaps better than, 




Fig. 60.— Goodell's Modified Ellmger Dilator. 

most other kinds. This instrument is constructed of two sizes, a 
small size with slender, and a larger one with powerful, blades 
which do not feather, and with a screw attachment to separate 
them. This screw attachment is a real advantage, for thereby we 
are enabled to dilate slowly, allowing the muscular fibres of the 
cervix to yield to the applied force, without rupturing. The 
larger one dilates to an outside width of one and a half inches. 
Truax & Co. have modified Ellinger's dilator, claiming also to have 
combined the desirable improvements of Groodell. This instrument 
(Fig. 61) is constructed on an entirely different principle from other 




Fig. 61.— Truax's Modified Ellinger Dilator. 

dilators. The blades dilate perfectly parallel, even under heavy 
pressure. The expansion is produced by a screw movement oper- 
ated by a milled wheel in the base of the instrument. The handle 
is provided with a gauge marking the amount of dilation, which is 
an important consideration. Sims' dilator (Fig. 62) has three 
blades, and is a very powerful instrument. Palmer's dilator (Fig. 
63) is an excellent instrument. It will dilate one inch, which is 
sufficient for most purposes. Moleworth's acme dilator deserves 
mention as an excellent instrument to produce slight dilatation, for 
curetting or in case of stenosis of the cervix, but as it expands 
only about half an inch it will not answer for general diagnosis 
where the finger has to be introduced. As far as it goes I consider 
it the best and safest instrument of the kind that has yet been de- 



INSTRUMENTAL EXAMINATION. 



59 



vised. It is provided with a channel through which intra-uterine 
injections can be made with comparative safety. 

Dilation having been accomplished, by whatever means, the 
linger, well cleansed and dipped in carbolized oil, is introduced 
through the dilated os and made to explore the uterine cavity. If 
no further procedures are required the cavity is thoroughly irri- 




Fig. 62.— Sims' Uterine Dilator. 



gated with hot water, and the patient allowed to remain quietly in the 
dorsal position until the uterus has resumed its normal condition. 
(7) The Cukette. — Sometimes, after the uterus has been 
dilated, it becomes necessary to scrape off portions of the diseased 
tissue for microscopic investigation. For this purpose an instru- 
ment is employed known as the curette, which is also used thera- 




Fig. 63.— Palmer's Uterine Dilator 



peutically for the removal of abnormal endometric granulations, 
sarcoma of the mucous membrane, carcinoma of the cervix, or the 
remains of an incomplete abortion. 

The curette as originally devised by Recauner (Fig. *64) has a 




Fig. 64. — Recauner's Curette 



sharp edge, as has also Sims' later design (Fig. 65). Simon's 
curette (Fig. 66) is a cup-shaped scoop or apron of steel, of vari- 



Fig. 65. — Sims' Curette. 

ous sizes and shapes. Thomas devised a curette made of flexible 
wire with a dull edge (Fig. 67). This has proved a very popular, 
safe and effective instrument, and has almost entirely superseded 



60 



A TEXT-BOOK OF GYNECOLOGY 



those made with a cutting edge. The dull wire curette is made in 
three sizes, has a flexible shaft which admits of being bent to any 
desired curve, and the scraping edge is smoothly flattened so as to 
prevent injuring the endometrium. Prof. A. R, Simpson has 
modified Thomas' curette by adding a knob two and one-half 
inches from the point, which informs the operator of the depth to 




Fig. 66. — Simon's Curette. 

which the instrument is inserted, thus enabling him to use it with 
greater safety. Byforcl has devised a curette (Fig. 68) with the 
end in view of being able to use considerable force without doing 
injury. It is something after the pattern of Sims' sharp curette, 



Fig. 67.— Thomas' Dull Wire. 

but perfectly dull, and quite strong, although flexible in the shank. 
Dr. Byford says that he considers this instrument so safe when 
properly used, that he a occasionally employs it in office diagnosis, 
but would be afraid to use any of the others with the same 
freedom." 

To use the curette the patient is placed in the semi-prone 




Fig. 63.— Byford 1 s Curette. 

position, and Sims' speculum introduced, the cervix having been 
previously dilated if necessary, and the location and position of 
the uterus thoroughly ascertained by a bi-manual examination and 
the use of the sound. The curette is then curved to correspond 
with the uterine curve and carefully carried into the uterus, the 
distance it is introduced depending upon whether only a small 
quantity of the tissue is desired for microscopic examination, or a 
larger quantity for examination in gross or for therapeutic pur- 



INS TP, UMENTA L EXAMIXA TION. 



61 



poses. 



The method of using the curette in the latter case is more 



fully detailed in the chapter on chronic corporeal endometritis. 

* (8) The Aspirator. — This valuable instrument is often 
requisite for obtaining information as to the character and contents 
of abdominal and pelvic tumors. The aspirator (Fig. 69) consists 




Aspirator. 



of a receiver, an exhausting syringe, a set of tubular needles, and 
a connecting flexible tube supplied with the necessary stop-cocks. 
The air is exhausted from the receiver by means of the syringe, 
after which a needle duly connected is inserted into the tumor or 
abscess to be examined. Powerful suction is thus exerted upon the 
contents of the tumor, which, if not too thick and tenacious, will 
flow through the needle into the receiver. The needles are so del- 
icate that puncture by them is comparatively safe, but should 
always be practiced with caution. In superficial cysts and abscesses 
an ordinary hypodermic syringe will answer every purpose. Large 
sized aspirators are not required for diagnosis. Peaslee's aspirator 
(Fig. 70) is a fair sample of several of the smaller instruments 
that have been devised chiefly for diagnostic purposes. Allen's 
surgical pump, already mentioned, is provided with aspirating 
needles, as shown in (Fig. 71). and constitutes an aspirator for 
either diagnostic or operative purposes that possesses many advant- 
ages not found in any other instrument. Other aspirators either 
necessitate the use of a vacuum bottle or require the turning of a 
stop-cock every time the cylinder is filled. The latter work slowly, 
have valves that are easily clogged, and are usually unsatisfactory. 
The former require the emptying of the bottle every time it is filled, 
and the creating of a new vacuum, and, as they will not work at 
ail without a vacuum, they require an air-pump that will always be 
in perfect working order. 

The Allen surgical pump possesses no piston (requiring fre- 



62 



A TEXT-BOOK OF GYNECOLOGY. 



quent packing), valves or stop-cocks, and as it is used without a 
vacuum bottle, the time usually employed both in producing the 
vacuum and in emptying the bottle is saved. 




Fig. 70. — Peaslee's Aspirator. 

There is no possibility of its failing to work, and the operator 
may rest assured that it will not fail him in an emergency. Should 
the needle become clogged with coagula, debris, or other matter, 
it may be instantly cleared by simply reversing the current (i. e. : 
turning the crank in the opposite direction), without necessitating 



Fig. 71. — Aspirator Needle for Allen's Surgical Pump. 

its withdrawal. It works equally as well as an injector, the only 
change necessary being the placing of the free end of the tube in 
the fluid to be injected and the reversing of the current. This will 



INSTRUMENTAL EXAMINATION. 63 

be found of great value, for it will enable the operator to wash out 
a pus sack by injecting any desired solution. 

In gynecological practice the aspirator is chiefly used to make 
a differential diagnosis between the contents of ovarian, parovarian 
and other cysts, and ascitic fluids, and the contents of a hematocele 
or a pelvic abscess. Often the gross appearance of the fluid with- 
drawn will determine the diagnosis, but sometimes it becomes 
necessary to submit a portion of it to a microscopic examination. 



CHAPTER V. 



DISEASES OF THE VULVA. 



Malformations. Hernia. 



Malformations. 
may occur: 



-The following malformations of the vulva 



Absence of the vulva, or atresia totalis ; 

2. Hypospadias; 

3. Epispadias; 

4. Hermaphrodism. 

In addition to these varieties there may also occur an absence 
or rudimentary formation of the clitoris and of the labia minora, 
whether on one or both sides, or there may be an enlargement of 
these tissues, as has already been noted in Chapter I. 

Vulva inf antalis is a condition in which there is an arrest in de- 
velopment after birth, the vulva retaining the dimensions of infancy. 

1. Absence of the Vulva. — This condition is sometimes 



a - 




Fig. 72. — Hypospadias: a, open canal, formed by the anterior wall of the 
urethra, the posterior being absent in this part; b, posterior, closed part 
of the urethra; c, hymen; d, opening in the same. (From Winckel, 
after Mosengeil.) 

known as atresia totalis, and is due to an arrest in development 
at the very earliest period of foetal development. All of the ex- 



DISEASES OF THE VULVA. 



65 



ternal genitals are absent, together with the anus and urethra, 
there being no external openings whatever, the rectum, bladder 
and genital canal usually communicating internally. This condi- 
tion, combined with other malformations, has been found only in 
non-viable monstrosities, and is, therefore, of no practical interest. 

2. Hypospadias. — This is a condition in which the posterior 
wall of the urethra is defective. The defect may extend so far up 
that control over the bladder is lost. Winckel says that a true 
hypospadia occurs ' ' when the bladder opens without the vagina 
into the vestibule." 

3. Epispadias. — This condition consists in a failure of the 




Fig. 73. — Epispadias: 
fZ, labium minus; 
Kleinwachter.) 



a, fissure in the bladder; b, labium majus; c, clitoris; 
e, hymen; /, vaginal entrance. From Winckel, after 



urethra and anterior parts of the vulva to close, leaving a cleft, 
which is usually combined with a cleft of the anterior wall of the 
bladder. The clitoris and nymphse may also be cleft. There is 



66 A TEXT-BOOK OF GYNECOLOGY. 

no urethra, the mUCous membrane of the open bladder presenting 
in the upper part of the vulva, just below the symphysis pubis. 

If hypospadias or epispadias are present in but a slight 
degree, they may perhaps be relieved by a plastic operation, but, 
as a rule, this is not the case, and treatment must be confined to 
an attempt to close the opening in the bladder by means of a com- 
press which presses the posterior against the anterior wall. 

4. Hermaphrodism. — This term is applied to those cases in» 
which a malformation of the female genitals exists in such a man- 
ner as to cause them to show a resemblance to the male organs, 
but it should be restricted to cases where the organs and character- 
istics of the two sexes become more or less blended in one indi- 
vidual. 

"Here some parts of the vulva, especially the clitoris and 
labia majora, are developed to an unusual degree. The labia, 
uniting at a higher level, present a sort of raphe, and not infre- 
quently contain the sexual glands, increasing the resemblance to 
the scrotum. On the other hand, other parts have been arrested 
in development, particularly the nymphae, and hence the glans is 
partially exposed. But usually such cases are not examples of 
true hermaphrodism, but of individuals of only one sex. There 
are, however, cases of true hermaphrodism, in which testicles and 
ovaries may be microscopically demonstrated in the same indi- 
vidual; but, as a rule, the parts peculiar to one sex are tolerably 
well developed, while the others are rudimentary. 

"The following combinations are possible: — 

u (a). Bilateral hermaphrodism, when a testicle is found on 
each side. 

" (b). Unilateral hermaphrodism, when an ovary or a testicle 
is found on one side and on the other both ovary and testicle. No 
case of this kind has been observed. 

" (c). On the other hand, numerous cases of lateral hermaph- 
rodism have been observed, i.' <?., a testicle on one side and an 
ovary on the other; this has been proved microscopically by care- 
ful observers." (1). 

Many interesting cases of hermaphrodism are reported, but 
the limits of this book preclude their repetition. 

In spurious hermaphrodism, so-called, a variety of operative 
measures may be indicated and prove of benefit, according to the 
nature of the malformation and its effects, but in true hermaphro- 
dism no operation is admissible, the subject being of practical 
interest only from the standpoint of diagnosis, especially in early 
life, on account of the bringing up of the child. In such cases, 
where a positive diagnosis cannot be made, Lawson Tait's advice 

1) Winckel, Diseases of Women. Parvin, p. 28. 



DISEASES OF THE VULVA. 67 

is good, to bring up the child as a male, as it will then be more 
apt to receive a knowledge of the sexual relations that will enable 
it to decide from its own knowledge and instincts its proper place 
in the sexual sphere. Then, too, male hcrmaphrodism is much 
more common than female, and there would consequently be less 
danger of a mistake, which might, if made by adopting the 
opposite method, result in considerable injury to others, as well as 
to the individual himself. 

Hernia of the Vulva. 

Anterior Labial Hernia. — Episiocele. — In this variety of 
hernia of the vulva, portions of the abdominal contents pass along 
the round ligament and appear in one or both labia majora, in a 
manner exactly analogous to scrotal hernia in the male. The 
hernial sac may contain the omentum, intestine, ovary, Fallopian 
tube, and, according to some authors, even the pregnant uterus. 
The condition is often congenital, but not necessarily so. 

The methods of diagnosis and treatment are practically the 
same as in all cases of inguinal hernia. 

Pudendal Hernia. — Posterior Labial Hernia. — Hernia 
Vagino-Labialis. — There is also a posterior labial hernia, where 
the hernia "passes down in front of the broad ligament into an 
opening or rent in the pelvic fascia and levator ani, and appears at 
the posterior extremity of one of the labia majora." (1) This 
variety is extremely rare. 

Diagnosis. — This is important, owing to the danger of for- 
getting the probability of a hernia in this position, and acting 
without regard to it a disastrous mistake might be made, as in one 
case recorded, where the hernial sac was punctured under the sup- 
position that it was a labial abscess. Thomas, in one case, came 
near making the same mistake. The same diagnostic rules apply 
as in other forms of hernia. 

The treatment is the same as in other inguinal hernia, either 
by taxis or operation. 

1) Winckel, Op. Cit., p. 34. 



CHAPTER VI. 



TUMORS OF THE VULVA. 

Cysts. Neuroma. Fibroma. Lipoma. Elephantiasis. Lupus. Sarcoma. 
Carcinoma. Hematoma. 

Tumors of the vulva require but brief mention. 

Cysts. — Cysts of the vulvo-vaginal glands are not of unusual 
occurrence. They may form from dilatation of the ducts or of the 
glands themselves. They are true retention cysts arising from 




Fig. 74.— Cyst of the duct of the vulvo-vaginal gland. 

obstruction in the ducts. They never grow to any considerable 
size, and are smooth and round, sometimes, if involving the whole 
gland, becoming lobulated. Another form of cyst of the vulva is 
usually found between the orifice of the urethra and the clitoris. 
Other forms of cysts are also found in other parts of the vulva, 
being sometimes very deep seated. 

The contents of the cysts of the vulva are usually a clear 
watery fluid, sometimes of a dark brownish fluid, frequently 
becoming purulent. 

Symptoms. — These are simply such as arise from the discom- 
fort of the swelling, especially when walking, and occasionally 
from the difficulty caused in sexual intercourse, though they are 
usually not of sufficient size to make much trouble. 

Diagnosis. — The position of the swelling and its fluctuating 



TUMORS OF THE VULVA. 69 

character usually renders the diagnosis easy. If not, tapping with 
a hypodermic needle will settle the question. 

Treatment. — The cyst should be extirpated, its walls being 
carefully dissected from the surrounding tissues, or the contents of 
the cyst having been evacuated the walls may be destroyed by the 
cautery. Sometimes it is sufficient to paint the sac with iodine or 
apply carbolic acid. 

Neuroma. — These are small nodular or papillary tumors, hav- 
ing a red appearance, and are exquisitely painful, resembling a 
urethral caruncle. They are found on the labia minora and in the 
vestibule. They should be removed either with the knife or 
scissors. 

Fibroma. — These are found springing from the labia majora, 
being pediculated or embedded in the cellular tissues and muscular 
portions of the vulva. They are easily extirpated if embedded, 
and if pediculated may be removed by the' scissors. 

Lipoma. — These are of more rare occurrence than fibroma, 
but may attain a large size, even hanging down to the knees. 
They often grow rapidly, and are somewhat sensitive, and often 
accompanied by more or less burning, so that they are liable to be 
confounded with sarcoma. They should be removed by the knife. 
Remedies have but little influence over lipoma, but the following 
may be consulted: Baryta carb., Calcarea carb., Phosphorus, 
Phytolacca. 

Elephantiasis. — This form of vulvar hypertrophy is much 
more common in the tropical countries, but minor cases are some- 
times met with in Europe and America. 

Varieties. — Elephantiasis is divided into the hard and soft 
varieties, and these again into the smooth, warty and papillary 
forms. Klebs makes three divisions, according to the nature of 
the disease. 

1. Lymphangectomatic, 

2. Epidermoidal, and 

3. Elephantiasis of the connective tissue. 
Pathology. — There is an immense proliferation of the con- 
nective tissue, with a great amount of serous infiltration. The 
lymphatic ducts and spaces are dilated, and the skin is thickened. 
The latter may remain smooth or become rough from enlargement 
of the papillae. Sometimes the lymphatics are not affected, the 
veins being dilated instead. 

Etiology. — Elephantiasis occurs most frequently between 
the twentieth and thirtieth year, seldom after the fortieth, and 
while influenced more or less in its development by menstruation 
and pregnancy, yet genital disturbances cannot be said to act as 
causes either predisposing or exciting. Nevertheless onanism and 



70 A TEXT-BOOK OF GYNECOLOGY. 

other mechanical irritations, excessive venery, and especially 
syphilis, are said to cause the disease. The frequency of the 
disease in tropical countries shows that climatic conditions exert 
some etiological influence. Winckel says that it seems probable 




Fig. 75.— Elephantiasis of the Labia. (From Scanzoni.) 

that ' ' wholly specific causes are to be sought for, probably in a 
peculiar bacillus which may be similar to the bacillus leprae." 

Symptoms. — These are mostly such as result from the weight 
and annoyance arising from a large tumor, which sometimes 
extends to the knees, and weighs twenty to thirty and sometimes 
fifty pounds. There is also more or less pain originating from 



TUMORS OF THE VULVA 71 

the fissures at the base of the swelling, and frequently a copious 
secretion is poured out. The general health is usually not much 
affected, though the continually unpleasant odors from the secre- 
tions, and from the superficial ulcerations which may take place, 
the dragging and pulling upon the urethra and difficult urination, 
may bring about disturbances of general nutrition, loss of sleep 
and emaciation. 

The parts of the vulva generally attacked are the labia majora, 
clitoris and labia minor, the clitoris being most frequently affected. 
The course of the disease is variable, sometimes developing very 
rapidly, while at other times the growth increases so slowly as to 
require twenty years or more for its full development. 

Diagnosis. — The diagnosis is readily made on inspection, 
unless extensive ulcerations lead us to suspect carcinoma, in which 
case a microscopical examination of the tissue may be required. 
The presence of yellow elastic tissue will serve, to distinguish it 
from fibroma. 

Treatment. — This consists in the removal of the tumor 
either by the knife, scissors, Paquelin's cautery, or the galvano- 
caustic loup. If the tumor has a broad base, involving consider- 
able of the vulva, it should be removed with the knife, and the 
wound united by sutures. Some cases have been cured by persist- 
ent use of a strong galvanic current. 

The medicines required will depend entirely upon the subjective 
and objective symptoms present. Probably Silicea is most often 
indicated. Consult Arsenicum, Clematis lodium, Hydrocotyle 
asiat., Sulphur, Thuja. 

Lupus. — Lupus rarely affects the vulva, but may do so in 
one or two forms — hypertrophic lupus and perforating lupus. 
The former is, more strictly speaking, a diffuse fibroma. 

Lupus may occur upon the labia majora, the clitoris, or the 
labia minora. The etiology of the disease is very obscure, and, 
notwithstanding the most earnest investigations, has up to the 
present time remained unknown. Recently Koch and Doutrelepout 
claim to have demonstrated the presence of the bacillis tuberculosis 
in lupus, and the result of their investigations are generally accepted 
as correct. 

Undoubtedly lupus of the vulva occupies a position on the 
boundary between benign and malignant growths. 

The course and pathology of this disease when affecting the 
vulva does not differ from lupus of other parts, and therefore will 
not be discussed. Suffice it to say that clinically lupus presents 4 ' a 
sore which alternately ulcerates and heals, creeping round the vulva, 
and leaving a depressed white scar to mark each step in its con- 
tinuous progress. The sores are preceded by flattish discolored 



72 A TEXT-BOOK OF GYNECOLOGY. 

tubercles, which are often very slow in ulcerating. As a rule, 
there is not much pain. Progress, though slow, is only too sure, 
and large tracts are covered with cicatricial contracted tissues before 
the disease comes to an end, if it does so during the life of the 
patient." 

Treatment. — It is usually considered that there is but one 
method of treatment, and that is to thoroughly remove the growth 
as quickly as possible by means of the knife, scissors, the galvano- 
cautery, or powerful escharotics. However, it should not be 
forgotten that numerous cases of cures of lupus with homeopathic 
remedies have been recorded, and this method of treatment is not 
to be entirely overlooked. The following remedies should be 
consulted : — Arsenicum, Arsenic iod. , Baryta carb. , Carbo an. , 
Carbo veg., Causticum, Conium, Hydrocotyle asiat., Graphites, 
Kali bichr., Kreasotum, Lycopodium, Phosphorus, Silicea, Staphy- 
sagria, Sulphur, Thuja. 

Sarcoma. — All varieties of sarcomatous tumors maybe found 
upon the vulva, but fortunately their occurrence is extremely rare. 
Their growth is usually very slow, and they are liable, without 
the aid of the microscope, to be mistaken for fibroma or lipoma. 
According to Hilderbrandt they sometimes break down and form 
an ulcer, which rapidly extends until the whole vulva may be 
involved. 

Symptoms. — These are neither characteristic nor very annoy- 
ing, except when friction gives rise to erosions and ulcerations. 
Often there is a marked tendency to hemorrhage, which greatly 
reduces the patient. 

Prognosis. — The prognosis is quite unfavorable, as when 
removed the tumor usually returns sooner or later, and the patient 
eventually succumbs. 

Treatment. — The tumor should be thoroughly removed as 
soon as possible either by the knife or cautery. 

Carcinoma. — Carcinoma of the vulva is more frequent than 
sarcoma. By far the most frequent form is the epithelioma," but 
genuine fibroid or ulcerative carcinoma may occur. The disease 
first appears as small round nodules under the skin or mucous 
membrane. Their growth is at first slow and painless, but after 
ulceration sets in they develop more rapidly and give rise to great 
annoyance and sometimes considerable pain. The inguinal glands 
on the side first affected are early involved and eventually become 
the seat of cancerous glandular ulcers. The disease seldom extends 
into the vagina 

Usually death results within two years after ulceration begins, 
from exhaustion due to septic poisoning. 

Treatment. — Doubtless the proper treatment is an early and 



TUMORS OF THE VULVA. 73 

complete removal. After the tumor becomes immovable and the 
inguinal glands are involved an operation will only hasten a fatal 
termination. In such cases the patient's life may be materially 
prolonged by the persistent use of the indicated remedy. The 
remedies most often called for are Arsenicum, Carbo an., Krea- 
sotum, Silicea. 

Hematoma. — This is a tumor formed by the effusion of 
blood into the tissues of the vulva from the rupture of a vessel 
beneath the surface. It is sometimes termed "thrombus" and 
"pudendal hematocele," either of which terms is evidently incor- 
rect. Hematoma arises almost exclusively from trauma, and are 
most common during parturition or pregnancy, but may occur 
independent of these conditions, as a result of a blow or violent 
muscular effort. Care must be taken to differentiate hematoma 
from labial abscess or pudendal hernia. 

Treatment. — Small hematoma are usually absorbed sponta- 
neously. If this does not occur the patient should be kept quiet 
and receive Hamamelis both internally and externally, which will 
sometimes facilitate absorption. If the tumor is large and causes 
considerable tension, it may be incised, the blood clots turned out, 
and the cavity washed out frequently with a weak solution of 
carbolic acid, and dressed with carbolized lint. Sometimes hemor- 
rhage follows this operation, and if so it will be necessary to apply 
persulphate of iron, and exert pressure by packing the cavity with 
lint and applying a tight bandage, or by introducing a large 
tampon into the vagina. 

If suppuration set in, it should be encouraged by giving Hepar 
sulph. internally, and applying poultices to the part. 



CHAPTER VII. 

VARICOSE VEINS. (EDEMA. ERUPTIVE DISEASES. 
PRURITUS VULVAE. 

Varicose Veins. 

This condition, otherwise known as phlebectasia of the vulva, 
is liable to occur at all ages, and while most often taking place 
during pregnancy, it may also be present in the non-gravid state. 
Sometimes the dividing walls between the veins break down, giving 
rise to a varicose tumor, which may vary from the size of a walnut 
to that of an orange, or even larger. Should the vessels burst 
beneath the skin or mucous membrane, the blood becomes effused 
into the cellular tissue, forming hematoma, which has been con- 
sidered in the previous chapter. 

Treatment. — Hamamelis is the remedy most often useful. 
Consult also Arsenicum, Pulsatilla and Rhus tox. 

Pressure should be maintained either by a tightly-fitting T 
bandage, or a properly adjusted pad. The patient should not 
allow herself to become over-fatigued, and should assume the 
prone position several hours each day. If a vein should rupture 
externally, she should lie down at once and apply pressure to the 
bleeding point. 

(Edema. 

Owing to the great amount of loose connective tissue which 
goes to form the vulva, oedema of the part is quite liable to occur. 
It is usually secondary to other affections, such as renal disease, 
and less often to disease of the heart or liver. It occurs most 
frequently as one of the results of the pregnant state, and is often 
found in connection with vulvitis and vaginitis, especially when of 
gonorrheal origin. CEdema may also accompany other chronic 
pelvic inflammations, fibroid and ovarian tumors, and cancer of 
the uterus. In extreme cases the oedema may be so great that it 
results in gangrene and septicaemia. 

Treatment. — The remedies most often required are: Apis, 
Arsenicum, Cinchona, Ferrum, Kali Carbonicum, Lycopodium, 
Pulsatilla, Rhus tox and Sulphur. 

Eruptive Diseases. 
The vulva is liable to become the seat of anv form of erup- 



PRURITUS VXJLVM. 75 

tive disease. Erysipelas, eczema, herpes, prurigo, erythema, acne, 
papilloma and condylomata are not of rare occurrence. These 
affections, when attacking the vulva, present similar characteristics 
and require like treatment as when located on other parts of the 
body. 

Pruritus Vulvae. 

Definition. — An irritable condition of the nerves of the 
vulva producing excessive itching of the parts. 

Pathology. — Pruritus vulvae is not a disease, but only a 
symptom of pathological conditions existing elsewhere. Never- 
theless, it is of so frequent occurrence, and so persistent and 
annoying in its character, while at the same time the cause which 
produces it may be so remote and obscure, that the symptom 
becomes, from a practical standpoint, the disease with which we 
have to contend. For this reason it deserves separate considera- 
tion. 

It is claimed by some authors that pruritus is often a true 
neurosis, accompanied by no anatomical lesion, but this theory is 
not generally accepted. The itching which accompanies eczema 
and other cutaneous diseases is not included in the term pruritus 
vulvae, yet, on account of the inflammation and excoriations of the 
parts caused by continual scratching, it is often difficult to deter- 
mine whether or not a primary eruption has existed. 

Etiology. — In endeavoring to ascertain the origin of pruri- 
tus in any given case the following list of possible causes should 
be carefully considered: (1) Irritating vaginal discharges — acrid 
leucorrhea, or from carcinoma; (2) Incontinence of urine; (3) 
Diabetes mellitus — due to the irritation of the sugar in the urine; 

(4) Lithiasis, oxaluria, or other irritating conditions of the urine; 

(5) External parasites — pediculi and acari; (6) Ascarides, or 
other parasites of the vagina and rectum; (7) Fungoid organ- 
isms; (8) Eczema or other local eruptions; (9) Local inflamma- 
tion — vulvitis, vaginitis, urethritis; (10) Vascular urethral car- 
uncle; (11) Short, bristly hairs growing on the mucous surface 
of the labia; (12) Apthous ulcers; (13) Pregnancy; (14) Men- 
struation; (15) Congestion of the pelvic organs; (16) Gouty or 
rheumatic diathesis; (17) Hyperaesthesia of the nerves. 

The observation that pruritus is often one of the earliest symp- 
toms of uterine cancer I have verified in two cases. I have also 
verified in several cases the observation of Fritsch, that pruritus 
vulvae is "frequently an affection of advancing age, of spontaneous 
occurrence." 

In addition to the above causes, pruritus may undoubtedly be 
brought about by indolent, luxurious or vicious habits; depreciated 



76 A TEXT-BOOK OF GYNECOLOGY. 

general health; want of cleanliness; excessive sexual indulgence; 
over-exertion, particularly walking, in persons of sedentary habits; 
feather beds and too warm clothing. 

Symptoms. — The primary symptom is an itching on the sur- 
face of the vulva, which comes on in paroxysms, and may be con- 
fined to a portion of the vulva, or involve all the external genitals. 
The paroxysms may occur at irregular intervals without apparent 
exciting cause, or may be occasioned by becoming overheated by 
exercise, from being near a warm fire, from getting warm in bed, 
from a fit of passion, while in other cases the paroxysms may only 
return at or near the menstrual period. In one class of cases the 
patient will complain of a burning glow accompanied by an irre- 
sistible desire to scratch or rub the parts, while in another a disa- 
greeable feeling of formication, as if a multitude of insects were 
crawling over the parts, is the sensation experienced. 

At first the irritability may be but slight, but it gradually 
becomes aggravated by scratching, until the misery becomes almost 
unbearable. Often the skin and mucous membrane become thick 
from rubbing, or covered with ulcers and eczematous eruptions 
from the use of the finger nails. Frequently the habit of mastur- 
bation is acquired, and this together with the continual irritation 
and annoyance may induce nervous depression and other secondary 
ailments. The condition is often obstinate and lasts for months and 
years, but more often it can be cured by a judicious combination of 
both constitutional and local treatment. 

Treatment. — While proper constitutional treatment is too 
often neglected in the treatment of pruritus, and in the majority of 
cases must constitute our main dependence, nevertheless it should 
be our first aim to discover and remove any local cause that may be 
present, when such a course is practicable. This may in some in- 
stances involve surgical measures, but more often it will require the 
use of topical applications, not only for the removal of local irri- 
tation, congestion, parasites, etc. , but also frequently for the palli- 
ation of the intolerable itching when arising from more profound 
causes. As Dr. Ludlam well says (1) : "It would be cruel to 
deny our patient the use of such palliatives as will mitigate her 
sufferings without in the least interfering with the cure of her 
complaint.''' 

A long list of preparations for local use that have proved more 
or less effective might be given. In fact, etiological as well as indi- 
vidual influences vary to such an extent that what may relieve one 
case may be of no benefit in another, and an application that may 
relieve a case promptly at one time, may afterward cease to be of 
benefit. 



1) Diseases of Women, 6th ed., p. 532 



PRURITUS VULVAE. 77 

If it be found that the trouble is due to parasites, these are 
best destroyed by the use of a five per cent, solution of carbolic 
acid, or of corrosive sublimate, half a grain to an ounce of water, 
or a lotion of equal parts of sulphuric acid and glycerine may be 
employed. 

For ascarides, a quassia infusion or a decoction of garlic may 
be used, or a cerate of carbolic acid may be smeared over the parts. 
Injections into the vagina and rectum of salt-and-water will often 
in such cases afford prompt relief. 

If eczema be present, the ordinary local applications for that 
disease may be employed. Almond oil medicated with a few drops 
of cantharis has been especially recommended. So, too, if vulvitis 
or vaginitis be present, the local treatment recommended elsewhere 
for those affections is equally serviceable. In such cases I have 
found very hot water applied on a sponge to be quite beneficial. 

In apthous ulceration there is probably nothing better than a 
solution of the biborate of soda, or a lotion of hydrastis. If the 
trouble arises from irritating discharges the usual injections for 
acrid leucorrhea may be employed. In such cases I have had good 
results from the use of an injection of hot water and biborate of 
soda. An excellent plan is to lightly pack the vagina with dry 
salicylated, borated or carbolized absorbent cotton. The patient 
can herself daily, or oftener, place a wad of this cotton just within 
the vagina, and thus obtain very considerable relief. At the same 
time, in this, as well as in other varieties of pruritus, it is a good 
plan to protect the irritated surface by the application of vaseline, 
or by dusting on starch, bismuth or lycopodium. I have obtained 
excellent results from the use of a glycerole of bismuth and 
dydrastia. 

Many other preparations have been recommended as a general 
application in pruritus: Chloroform and almond oil; cologne in 
warm water; starch and camphor; mercurial ointment; lime water; 
iodoform; tar and glycerine; infusion of tobacco; plantago cerate; 
nitrate of silver; acetate of lead and opium; conium; caladium 
seguinum, etc. I have obtained excellent results from the latter 
remedy, used both internally and externally. 

If the pruritus is due to the presence of stunted or broken 
hairs around the margin of the vulva, each of these must be 
removed with a pair of forceps, by the aid of a magnifying glass. 
If diabetes be the cause, the catheter should be used regularly and 
as frequently as necessary, and the parts thoroughly washed after 
each micturition. 

Under all circumstances cleanliness is of the utmost import- 
ance. The parts should be frequently bathed, and sitz baths, or 
vaginal injections of warm water and castile soap, be employed 



78 A TEXT-BOOK OF GYNECOLOGY. 

daily. Moderate exercise in the open air is desirable, but the 
patient should avoid fatigue or overheating of the body. The diet 
should be plain and unstimulating. Sexual intercourse should be 
permitted only in moderation. 

In no case should the use of the carefully selected remedy be 
neglected. While there may be cases in which the cause is entirely 
local, and a cure may be accomplished by the use of local and 
mechanical measures, yet it is oftener true that back of all lies a 
constitutional disease or dyscrasia which these measures only pal- 
liate, and which can never be cured without the use of internal 
medicine. 

Therapeutics. 

Ambra. — Especially useful when of purely nervous origin, or 
during pregnancy. Violent itching of the vulva; soreness and 
swelling of the labia; menses too early and too profuse; discharge 
of blood between the periods from every slight accident, as after 
hard stool or walking; urine deposits a brown sediment; patient, 
nervous and hysterical. 

Arsenicum. — Especially when resulting from uterine cancer, 
or from irritating discharges; burning and itching; vesicular or dry 
scaly eruptions, gangrenous tendency; worse at night, better from 
warmth and warm applications. 

Caladium. — An efficient remedy both internally and locally. 
No special indications other than it produces pruritus of the vulva 
and vagina, and has repeatedly cured the condition; also when asso- 
ciated with papular eruptions on the genitals. 

Cantharis. — Swelling and irritation of the vulva. Violent 
itching in the vagina. Pruritus with strong sexual desire. Dysuria, 
frequent micturition with burning and cutting pain. 

Carbolic Acid. — Useful both internally and externally when 
resulting from putrid, irritating discharges, and when there is a 
vesicular eruption which itches excessively, better after rubbing, 
but leaving a burning pain. 

Carbo Veg. — Red, sore places on the vulva; apthre (Helonias); 
itching, sore and raw during leucorrhea. Leucorrhea, thin in 
morning, on rising, not through the day; milky, excoriating. 
Menses too early and too profuse. 

Collinsonia. — Especially during pregnancy or when depend- 
ent on or associated with hemorrhoids, constipation or other rectal 
troubles; violent itching, parts badly swollen, dark red and pro- 
truding. 

Conium. — Especially in scrofulous or cancerous subjects; se- 
vere itching deep in the vagina; thick, white, acrid leucorrhea 
causing itching and burning. 



PRURITUS VULVJE. 79 

Graphites. — Itching of the pudenda before menstruation. 
Menses too late, too scanty and too pale. Vesicles or excoriations 
in the vagina, on the perineum, vulva, and between the thighs. 

Helonias. — Especially in anaemic women, with uterine atony, 
prolapsus and leucorrhea; apthous conditions; intense pruritus, 
parts hot, red and swollen, exfoliations of epidermis. 

Kali Bromatum. — Pruritus from ovarian or uterine irrita- 
tion; diabetes; urine loaded with sugar; incontinence of urine; ner- 
vous unrest. 

Kreasotum. — Violent itching of the labia, also of the vagina; 
external genitals swollen; hot, hard and sore; soreness and smart- 
ing between the labia and vulva. Itching during and after men- 
struation. Leucorrhea of a yellow color, staining linen yellow, 
with great weakness. 

Mercurius. — Leucorrhea, always worse at night, greenish 
discharge, smarting, corroding, itching, burning after scratching. 
Inflammation of vagina, and especially the external genitals, with 
rawness, smarting, and excoriating spots. Itching of the genitals, 
worse from the contact of urine. 

Nitric Acid.— Especially in syphilitic subjects, and those who 
have taken much Mercury; itching of the vulva; ulcers in the vag- 
ina, burning and itching; offensive leucorrhea. 

Petroleum. — Itching, soreness and moisture of external 
genitals; menses too early, the discharge causing excoriation and 
itching; eczematous eruptions. 

Platina. — In hysterical subjects, especially during pregnancy, 
voluptuous tingling extending from genitals into abdomen; nym- 
phomania; anxiety and palpitation of the heart; menses profuse, 
flow dark and clotted. 

Rhus Tox. — Resulting from acrid menstrual flow or erysipel- 
atous or eczematous inflammation of the vulva; much burning and 
itching. 

Sepia. — Long standing chronic cases associated with uterine 
displacement; or during pregnancy, child-bed, or while nursing; 
great dryness of the vulva and vagina, which are painful to the 
touch; soreness and redness of the labia, in the perineum and be- 
tween the thighs; excoriating leucorrhea, yellow like milk, or pus, 
or of bad smelling fluids. 

Silicea. — In scrofulous subjects; imperfect nutrition; itching 
burning and soreness in the vulva; acrid, corrosive leucorrhea 
eczematous, pustular or herpetic eruptions, with a tendency to 
suppuration. 

Sulphur. — Chronic cases in " psoric" patients; profuse yellow, 
corrosive leucorrhea; itching of the genitals, with papular erup- 
tions around them; burning in the vagina, is scarcely able to keep 



80 A TEXT-BOOK OF GYNECOLOGY. 

still; voluptuous itching and tingling, with burning and soreness 
after scratching; worse from the warmth of the bed. 

Consult also Calcarea carb., Croton tig., Hydrocotyle, Asia- 
tica, Lilium tig., Lycopodium, Mezerium, Natrum mur., Nux 
vom., Pulsatilla, Staphysagria. 



CHAPTER VIII. 



VULVITIS. 

Vulvitis. Hyperesthesia of the Vulva. Urethral Caruncle. 
Prolapsus of the Urethra. Coccyodynia. 

Vulvitis. 

Definition. — Inflammation of the vulva. 

Varieties. — There is much difference of opinion as to the 
proper classification of vulvitis. I shall, however, only mention 
the various forms of simple vulvitis, not including the exanthem- 
atous and the infectious varieties — eczema, herpes, prurigo erysip- 
elas, diphtheria and syphilis — for these affections, when involving 
the vulva, do not differ materially from like conditions existing 
elsewhere. 

Four varieties of simple vulvitis may be distinguished : — 
(1) catarrhal ; (2) gonorrheal ; (3) follicular ; (4) gangrenous. The 
first two varieties are frequently included under one head as puru- 
lent vulvitis. 

1. — Catarrhal Vulvitis. 

Pathology. — Catarrhal vulvitis may only involve the mucous 
membrane, which presents a red, inflamed appearance, or it may 
involve the corium and subcutaneous tissue, constituting what is 
sometimes separately described as phlegmon of the vulva. In 
such cases the skin is greatly swollen and presents a red or bluish- 
red color, is more or less cedematous, and not infrequently the 
glands of Bartholini inflame and suppurate, forming an abscess 
which is usually about the size of a pigeon's egg. 

Acute catarrhal vulvitis is of rare occurrence in the adult, but 
is quite common in children. It rarely involves the vagina, being 
confined to the vulva alone. 

Sub-acute and chronic catarrhal vulvitis is more common in 
the adult, as might be inferred from the character of the causes 
which produce it. 

Etiology. — Acute catarrhal vulvitis, as it occurs in young chil- 
dren, is most often the result of a want of cleanliness, the external 
genitals being continually irritated by the presence of urine and 
feces upon the parts. It may occur during dentition, especially in 
scrofulous children. In adults it may occur from injuries and sur- 
gical operations, awkward and immoderate coitus, and from irri- 
tating discharges. 



82 A TEXT-BOOK OF GYNECOLOGY. 

The sub-acute and chronic forms usually arise from the influ- 
ence of irritating vaginal discharges, either menstrual or leucor- 
rheal ; or, from urinary fistula, carcinoma, diabetes, or an exten- 
sion of vaginitis. According to Winckel 4 ' the vulvitis of diabetes 
presents a peculiar copper-red color." Onanism and excessive 
venery must not be overlooked as not infrequent causes. 

Symptoms. — The first symptoms are heat, dryness, burning, 
pain and moderate swelling of the parts, soon followed by a more 
or less profuse flow of muco-pus, which affords some relief. There 
is also usually considerable tumefaction, hypersensitiveness and 
pruritus, and sometimes painful' menstruation. If the deeper 
tissues are involved and suppuration sets in, the primary symptoms 
are soon followed by shooting pains and throbbing in the affected 
parts, and the presence of an abscess is soon apparent. 

An acute attack usually lasts from one to three weeks, often 
longer in children. The sub-acute and chronic forms may run a 
lengthy and tedious course unless properly treated. 

Treatment. — In the acute form, rest in bed, hot fomenta- 
tions, and the use of the indicated remedy — usually aconite or 
belladonna — are the chief indications for treatment. Frequently 
the hot fomentations may give way, with benefit, to the use of 
fluid Calendula or fluid Hydrastis, one-half ounce to a pint of tepid 
water, applied by saturating a piece of soft linen cloth. After the 
secretion is established, the parts must be kept carefully cleansed 
by frequent douches of tepid water. If suppuration threatens and 
Belladonna or other indicated remedy fails to produce resolution, 
efforts should be made to hasten the suppurating process. Hot 
poultices should be applied and Hepar sulph. given in a low 
trituration. The abscess should be evacuated early on account of 
the danger of the burrowing of pus in the lax surrounding tissues. 
It is said that sometimes the pus will even force its way upward 
and through the abdominal ring. 

In the sub-acute and chronic varieties the chief local treat- 
ment consists in removing all irritating discharges. For this pur- 
pose an injection of a two per cent, solution of carbolic acid may 
be used, together with frequent hot vaginal douches, and a wad of 
carbolized or borated absorbent cotton may be placed inside the 
vagina to absorb the discharges. The external parts should occa- 
sionally be washed with a Hydrastis or Calendula lotion, and then 
kept dressed with vaseline applied on a soft linen cloth. 

2. — Gonorrheal Vulvitis. 

Acute vulvitis in the adult is almost invariably the result of 
gonorrheal infection. 

Symptoms and Diagnosis. — The symptoms in the main do 



VULVITIS. 83 

not differ from those of catarrhal vulvitis, so that it is often impos- 
sible to positively differentiate between the two. This sometimes 
becomes a very important matter, as upon the diagnosis may 
depend the reputation of a virtuous woman and the happiness of a 
family. In the gonorrheal variety the acuteness and suddenness 
of the attack, the apparent absence of other causes, the presence of 
a violent urethritis, which is never present in the catarrhal form, 
the presence of pus in the urethra and the thick yellow or greenish 
purulent discharge from the inflamed surfaces will generally estab- 
lish the nature of the disease. Extension to the vagina more often 
takes place, and labial abscesses are much more common, than in 
the catarrhal variety. 

The fact that transmission to the male has taken place is not 
a positive sign of gonorrheal origin, as a severe balanitis in the 
male may result from connection with women suffering from non- 
specific irritating vaginal discharges. In some cases of gonorrheal 
vulvitis condylomata form around the vaginal orifice, which never 
occurs in the catarrhal variety. However, as Dr. Helmuth well 
says, ' ' in many cases there is an impossibility to pronounce posi- 
tively as to the presence of gonorrhea in the female." 

Treatment. — The treatment of gonorrheal vulvitis does not 
differ materially from that of the catarrhal variety. Frequent hot 
vaginal douches, injections of a two per cent, solution of carbolic 
acid, or what is still better in this variety, of bi-chloride of mer- 
cury, one grain to a pint of water, or the use of Calendula and 
Hydrastis, as before mentioned, are the most effective local appli- 
cations. 

The following remedies are most often required, according to 
the symptoms : — Aconite, Belladonna, Canabis sativa, Cantharis, 
Mercurius sol., Nitric acid, Phytolacca, Sulphur, and Thuja. 

3.— Follicular Vulvitis. 

Pathology. — In this variety the sebaceous sweat and hair 
follicles of the vulva are especially affected. They become enlarged 
to the size of a pin-head, forming slight elevations or little red 
prominences over the vulva, which secrete pus, the condition thus 
presenting the appearance of granulations. Sometimes the secre- 
tion is less purulent, and more of a white, cheesy or pasty charac- 
ter, which in bad cases may form a thick coating over the entire 
inflamed surface. In some instances the mouths of the glands are 
stopped, the secretion being retained and a suppuration following. 

Etiology. — Uncleanliness is the chief cause of follicular vul- 
vitis. It may also be caused by pregnancy, vaginitis, exanthemata, 
excessive venery, but it is rarely, if ever, of specific origin. 

Symptoms. — There is much burning, itching, heat and sore- 



84 



A TEXT-BOOK OF GYNECOLOGY. 



ness in the vulva, which sometimes becomes excessively sensitive, 
even to the extent of producing vaginismus. Urethritis is fre- 
quently present. 

This form of inflammation is more severe than the catarrhal, 
and more inclined to run a chronic course, sometimes proving very 
intractable. If occurring as a result of pregnancy it will usually 




Fig. 76. — Follicular Vulvitis. 

disappear after parturition, but in very severe cases it is said to 
sometimes produce abortion. 

Treatment. — The local treatment is the same as in the catar- 
rhal variety. 

4.— Gangrenous Vulvitis. 

Pathology. — Fortunately gangrenous inflammation of the 
vulva is of rare occurrence. In children the condition is said to be 
identical with noma or cancrum oris, and probably in no case does 
the disease essentially differ from gangrene of other parts. Accord- 
ing to Winckel (1) u a slight infiltration first appears in one of the 
labia majora ; this soon has a grayish-green color ; vesicles are 
formed, the color then changes to a dark-brown, terminating in 
gangrene and loss of substance." 

Etiology. — Gangrene of the vulva when occurring in the 
adult is usually a result of parturition, when there has been exten- 

1) Diseases of Women, Parvin, p. 66. 



VULVITIS. 85 

sive oedema, or of some mechanical violence, or it may follow the 
rapture of a large hematoma. In some epidemics of puerperal 
fever it is present in nearly every case. It may also occur in the 
course of acute exanthematous diseases, and in continued fevers, 
and may exist as an epidemic independent of any other diseases. 

Prognosis. — The prognosis is unfavorable, most cases termi- 
nating fatally, death resulting from septicaemia, or pulmonary 
embolism. If recovery takes place, cicatrization occurs in from 
three to six weeks. 

Treatment. — In order to guard against septicaemia all slough- 
ing masses should be cut away, being careful to avoid living tissue, 
which should be thoroughly cauterized. As local applications, a 
solution of salicylic acid, thymol or lime water are recommended, 
or the parts may be dusted with iodoform, boric acid or chlorate 
of potash. I consider a charcoal poultice the best dressing that 
can be applied. Tincture of Baptisia also makes an excellent 
application. 

The patient should receive a nourishing diet, and if necessary 
be sustained by wine, brandy, or other stimulants. Arsenicum is 
the remedy most often required. I think it should be used in a 
low trituration. Also consult Baptisia, Carbo. veg., Crotalus, 
Kreasotum, Lachesis, Secale, Muriatic Acid, Nitric Acid, and 
Rhus tox. 

For the therapeutics of vulvitis in general the reader is 
referred to the chapter on Leueorrhea. 

Hyperesthesia of the Vulva. 

Definition. — A condition of rare occurrence and first de- 
scribed by Thomas (1) as "an excessive sensibility of the nerves 
supplying the mucous membrane of some portion of the vulva ; 
sometimes the area of tenderness is confined to the vestibule, at 
other times to one labium minus, at others to the meatus urinarius; 
and again a number of these parts may be simultaneously affected. 
It is a condition of the vulva closely resembling that hyperaesthetic 
state of the remains of the hymen which constitutes one form of 
vaginismus.'' 

Pathology. — There is neither a true neuralgic nor an inflam- 
matory state, but simply an abnormal sensitiveness of the nerves 
supplying the vulva. 

Etiology. — The condition may result from vulvitis or irritable 
urethral tumors, but more often it arises at or near the menopause, 
especially in hysterical or hypochondriacal patients. In some cases 
no cause can be discovered. 

Symptoms. — The chief symptom is pain on sexual intercourse. 

1) Diseases of Women, 1876, p. 114. 



86 



A TEXT-BOOK OF GYNECOLOGY. 



Any friction, or even cold air, produces great discomfort, and some- 
times intense pain. The mind becomes depressed, in some instances 
bordering upon monomania. 

Diagnosis. — It is necessary to differentiate from irritable 
caruncle of the meatus; and from vaginismus, which latter, it must 
be understood, is a distinctly different affection. Inspection and 
touch will readily distinguish between these conditions. 

Treatment. — This must be entirely symptomatic, the remedy 
being probably more often indicated by the general than the local 
symptoms. Consult Belladonna, Cimicifuga, Cocculus, Coffea, 
Gelsemium, Hyoscyamus, Ignatia, Kali brom. , Nux Vomica, Plat- 
inum, Thuja, Zincum. 

Urethral Caruncle. 

Definition. — A vascular tumor or irritable vascular excres- 
cence of the urethra. 

Pathology. — These tumors consist, according to Hart and 




FlG. 77. — Caruncle at Urethral Orifice (a) and, in addition, Neuromata in 
surrounding Mucous Membrane. (Sir J. Y. Simpson). 

Barbour, "of dilated capillaries in connective tissue, the whole 
being covered with squamous epithelium. " According to Dr. Reid, 
of Edinburgh, they are richly supplied with nervous filaments. 



PROLAPSUS OF THE URETHRA. 87 

They vary in size from that of a pin-head to that of a rasp- 
berry, or even larger ; they are of a deep cherry-red color, soft 
and friable, usually of an irregular shape, and are exquisitely tender 
and vascular. 

Symptoms. — These are — pain on micturition; severe pain, 
and sometimes hemorrhage, from coition ; and more or less 
disturbance and pain from pressure or friction, from exercise, or 
from the clothing touching the parts. The patient also becomes 
nervous, hysterical and melancholy. 

Diagnosis. — A urethral caruncle is liable to he confounded 
with urethral prolapsus, or with syphilitic warty growths, but as 
neither of these present the characteristic sensitiveness, pain and 
vascularity of urethral caruncle, there should be no mistake. 

Treatment.— The patient having been put under an anaes- 
thetic, is placed upon a table in the lithotomy position. The 
tumor is then grasped near its base by forceps and cut off by 
scissors. The base should then be thoroughly cauterized by 
Paquelin's thermo-cautery at a dull heat, or, in the absence of this 
instrument, by a hot wire. If hemorrhage continues after the use 
of the cautery it may become necessary to "plug the vagina, 
bringing the half of the last strips of lint over the urethral orifice 
and fixing with a perineal band.'' Some authorities, instead of 
using the cautery, touch the base of the caruncle with fuming 
nitric acid, or pure carbolic acid. 

Prolapsus of the Urethra. 

Definition. — An eversion or prolapsus of the mucous mem- 
brane lining the urethra. According to Thomas there is also a 
-•proliferation of the underlying connective tissue." 

Symptoms. — This condition often exists for some time without 
giving rise to any symptoms, but exposure and irritation of the 
prolapsed membrane after awhile leads to more or less urethral and 
bladder disturbances, pruritus and leucorrhea. 

Diagnosis. — There is more danger of confounding this condi- 
tion with urethral caruncle or polypus, but the fact that the 
swelling completely and uniformly encircles the urethra, that it is 
not vascular, and lacks the excessive sensitiveness and pain of a 
caruncle, > are sufficient to make the diagnosis easy, though a pro- 
lapsed urethra sometimes becomes very sensitive, and for this 
reason, as Thomas says, this symptom is not to be relied upon as 
a differential sign. 

Treatment. — Thomas recommends pulling down the pro- 
lapsed membrane with both forceps, and cutting it off with curved 
scissors, the resulting hemorrhage to be controlled by applying 



88 A TEXT-BOOK OF GYNECOLOGY. 

pledgets of lint or cotton saturated with a solution of per-sulphate 
of iron. 

Sequin avoided hemorrhage by introducing a female catheter 
into the bladder, and ligating the prolapsed membrane to it, so that 
strangulation ensued, leaving the catheter in until it was released 
by sloughing off of the ligated part. The same plan could be 
adopted, using the galvano-cautery wire instead of the ligature. 

COCCYODYNIA. 

Synonyms. — Coccygodynia, Coccyalgia, 

Definition. — A hyperesthesia and neuralgia of the coccyx 
and of the muscles attached to it. 

Pathology. — This condition is in some cases associated with 
disease of the bone itself, such as caries or fracture, and hence the 
real nature of the disease has sometimes been overlooked. Injury 
and disease of the bone are by far of more frequent occurrence 
than is the disease now under consideration. It is therefore evident 
that something more than a diseased bone is necessary to produce 
coccyodynia, which is now pretty well established to be a neurosis, 
and dependent upon a hyperaBsthetic and neuralgic state of the 
nerves supplying the region of the coccyx. This latter condition 
may arise from a variety of causes, either being reflex in its char- 
acter, or resulting from an injury or disease of the coccyx, or an 
injury or strain of its muscular attachments. 

Etiology. — From what has been said it is not surprising that 
parturition is the chief cause of coccyodynia. It may also occur 
in women who have never borne children, and sometimes, though 
rarely, has been found in men and young children. Outside of 
childbearing, it may be caused by mechanical violence, such as a 
kick, a blow, or a fall upon the coccyx, or from horseback riding. 
It is also frequently associated with uterine, ovarian or rectal 
disease. In persons of a rheumatic diathesis it arises from exposure 
to cold. 

Symptoms. — The chief symptom is pain on moving the os 
coccyx, in sitting down or rising from a seat, or in defecation, 
coughing, sneezing, or walking. Frequently the patient will 
suffer so much from any movement that she is obliged to keep in 
a recumbent posture. 

Diagnosis. — The finger should be passed into the vagina or 
rectum and pressed backward upon the cervix , or, with the thumb 
outside, the bone can be seized and caused to move, which will give 
the patient great pain. This, together with the history of the case, 
is sufficient to establish a diagnosis. 

Prognosis. — There is but very little tendency to spontaneous 
recovery, the disease lasting for years, causing the patient con- 
tinual annoyance and distress, unless relieved by proper treatment. 



COCCYODYNIA. 89 

Treatment. — Remedies should be persistently employed 
according to indications, but at the same time the cause of the con- 
dition must be ascertained and removed if such a thing is possible. 
In cases resulting from uterine displacement, or ovarian or uterine 
disease, the primary disease must be removed before the coccyo- 
dynia can be cured. So, also must anal fissures, hemorrhoids and 
ulcers in the rectum be watched for, and if found, removed by 
appropriate treatment. 

In selecting a remedy all existing circumstances must be taken 
into consideration, and all the symptoms of the case covered if it 
is possible to do so. 

The following remedies arc especially to be considered : Bel- 
ladonna, Cinchona, Cimicifuga, Colocynth, Ignatia, Kali brom., 
Lachesis, Lilium tig., Mercurius, Nux Vomica, Platina, Plumbum. 
Pulsatilla, Rhus tox., Sulphur and Zinc. 

If the condition persists in spite of all these measures, it may 
be necessary as a last resort to adopt surgical measures. There are 
two operations which have been successfully practiced. The first 
consists in passing a tenotomy knife beneath the skin on the pos- 
terior aspect of the coccyx, and freeing its lateral and apical 
muscular attachments. The second is amputation of the coccyx. 
This operation consists in first making a vertical mesial incision 
over the posterior aspect of the coccyx, and dissecting away the 
integument and muscular attachments, after which the bone is lifted 
up and turned backward so as to expose the articulation, which is 
then separated by the use of the bone-forceps or a strong knife. 

The wound is then closed by replacing the flaps and uniting 
them by sutures. 

This operation is very effective, and is neither dangerous nor 
difficult to perform. 



CHAPTER IX. 

DISEASES OF THE VAGINA. 

Malformations. Atresia. 

Malformations. — Malformations of the vagina, like those 
of the uterus, occur from imperfect development, destruction, or 
failure of coalescence of the ducts of Miiller, the lower extremities 
of which should unite to form the vagina. A full description of 
these malformations will not be attempted in this work, though 
each one will receive brief mention. It is a safe rule to follow 
that no efforts should be made to correct these conditions surgi- 
cally. Especially is this true in those cases in which it is desirable 
to make an artificial vagina, unless it is demanded by the presence 
of a hematometra. Malformations of the vagina are : — • 

(1). Absence of the vagina. 

(2). Rudimentary vagina. 

(3). Unilateral vagina. 

(4). Double vagina. 

(5). Congenital smailness of the vagina. 

(6). Congenital cloaca of the vagina. 

1. Absence of the Vagina. — This condition is very rare, 
for even in those cases in which the vagina is supposed to be absent, 
bands of connective tissue are usually found running in the natural 
course of the vagina, and these bands must be considered to be 
rudimentary formations, even as they are in the uterus. 

According to Winckel, absence of the vagina ' ' occurs only 
in connection with a defect of the vulva or uterus." Cases are on 
record, in which the uterus has been sufficiently developed to per- 
form its functions, and yet the vaginal canal was entirely absent. 
In such cases the condition becomes of practical interest, owing 
to the necessity of affording relief to the patient. 

The symptoms, and the methods for their relief, are prac- 
tically the same as those indicated under atresia of the vagina, 
which, when congenital in its origin, is essentially the same as this 
condition. 

2. Rudimentary Vagina. — This may consist only of a blind 
pouch immediately back of the hymen, which, if the hymen were 
absent, might mislead one into supposing the condition to be that 
of imperforate hymen. Such a blind pouch may also exist near 
the cervix, or two such pouches may be present; separated by 

90 






DISEASES OF THE VAGINA. 91 

more or less membranous tissue. The condition is essentially 
equivalent to an entire absence of the vagina, and the treatment is 
the same as in atresia vagina. 

3. Unilateral Yagixa. — This malformation occurs espe- 
cially in connection with the uterus unicornis, only one of Miiller's 
ducts having developed in the vaginal region, forming but one- 
half the vagina. The condition is not of practical interest, and is 
difficult of demonstration. 

4. Double Yagina. — As has already been noted, when there 
is a double uterus the septum usually extends downward, forming 
in addition a double vagina, the hymen being also usually double. 
Cases are recorded wherein the vagina alone is double ; but in such 
cases one side is always rudimentary. When both halves are 
equal, the septum may be so thin and so easily distended, that one 
side is readily dilated at the expense of the other. The septum 
may also occur in the middle of the canal, forming equal halves ; 
or, one side may be narrower than the other. Sometimes the 
septum is present only in the lower, or in the upper part of the 
vagina, its usual seat being at the junction of the upper with the 
middle thirds of the canal. 

5. Coxgexital Smallness of the Yagixa. — This is usually 
associated with some malformation of the uterus, more especially 
the foetal, or infantile uterus, but it may also exist independently of 
these conditions. The canal may be so small as to admit only an 
ordinary catheter, or it may be large enough to permit coitus and 
not interfere with parturition. The narrowness may exist, as it 
usually does, throughout the whole canal, or it may affect only a 
portion, or several distinct portions, a condition resulting evidently 
from inflammatory processes in the foetus. 

6. Coxgexital Cloaca of the Yagixa. — By this term is 
understood a malformation in which the rectum and vagina, and 
sometimes the bladder as well, open into a common external orifice. 
In such cases the external anus is either absent or occluded, and 
the contents of the rectum are evacuated through the opening into 
the vagina. Sometimes the opening is small, and is provided with 
a sphincter, so that evacuations take place regularly and without 
much inconvenience. More often, however, this is not the case, 
and inversion or prolapsus of the rectum takes place through the 
large opening, the stools are involuntary, and the patient suffers 
from the annoyance and uncleanliness in spite of all efforts to the 
contrary, though no conditions arise which endanger life unless the 
rectum, having bent at a right angle, allows a retention of feces in 
the pouch thus created, followed by the usual symptoms of intes- 
tinal obstruction — stercoraceous vomiting, peritonitis and death. 

Progxosis. — In those cases in which the condition has not 



92 A TEXT-BOOK OF GYNECOLOGY. 

already produced a disease of the rectum, or where there are no 
co-existing malformations of a serious character, cloaca of the 
vagina can be remedied by a comparatively simple operation, and 
the fecal evacuations made to occur in the normal way. 

Treatment. — The surgical treatment of the malformation 
consists in making an incision of about one inch in length in the 
perineum, from before backward, and sufficiently deep to expose 
the rectum, the lower portion of which is loosened from the sur- 
rounding tissues by means of a blunt hook. The rectum is then 
severed from its vaginal connection, and its opening attached, by 
means of sutures, to the opening in the perineum. The edges of 
the vaginal opening are then freshened and closed by sutures. 
Winckel says (1) that "after the rectum has been separated from 
the vagina, the opening in the latter soon becomes so reduced in 
size that it may be closed by cauterization. When there are nar- 
row, fistulous canals in the perineum, they should be opened into 
the rectum, separated from the intestine, and the sutures passed 
backward to the coccyx.' 1 

Atresia Vaginae. 

Definition. — A congenital or acquired occlusion of the 
vaginal canal. The term signifies a complete closure of the canal, 
but it applies also to cases in which the occlusion is so nearly com- 
plete that only a probe or sound may be passed through the 
remaining orifice. The obstruction may be at the hymen, when it 
is known as atresia hymenalis, or imperforate hymen, or it may be 
anywhere in the course of the canal. 

Pathology. — Atresia hymenalis is always congenital. The 
hymen, not being perforated, forms a continuous membrane which 
entirely occludes the vaginal entrance. The membrane is always 
thicker than normal. The condition is not recognized until atten- 
tion is called to a retention of the menstrual fluids. The accumu- 
lation of blood causes the hymen to bulge, and at the same time it 
dilates the vagina. If not soon relieved, perforation into the 
bladder or rectum may occur, or the dilatation may involve the 
uterine canal, and even the Fallopian tubes, though it is claimed 
that the distension of the latter occurs from hemorrhage from the 
mucous membrane of the tubes themselves, the uterine ends being 
undilated. Rupture of the uterus or of the Fallopian tubes may 
take place, or pelvic hematocele may form, caused by the blood 
escaping from the fimbriated extremities of the tubes. 

Atresia vaginalis may be either congenital or acquired. If 
congenital, it may result from an arrest of development of Midler's 
ducts, constituting what has already been described as a congenital 



1) Diseases of Women. Parvin, p. 124. 



DISEASES OF THE VAGINA. 93 

absence of the vagina, or these ducts may have developed more or 
less imperfectly, so that but a portion of the canal remains obliter- 
ated, or a thick, firm membranous band may pass from one por- 
tion of the canal to another, causing a transverse occlusion — mem- 
branous atresia of the vagina. Acquired atresia may occur at any 
point in the vaginal canal, and be of greater or lesser thickness, 
according to the nature of the various conditions which give rise 
to it. It inmost often located at the lower third, and might be 
mistaken for an imperforate hymen, but that retained fluids cause 
no bulging. 

The atresia may be complete, but more often one or more 
small orifices exist, through which a probe may be passed, though 
these are frequently difficult to find. In such cases, dilatation 
does not occur to such an extent as in congenital atresia, sufficient 
blood escaping to prevent this disaster. In partial atresia, concep- 
tion has been known to occur, and the condition discovered only at 
parturition. Complete atresia may give rise to similar pathologi- 
cal changes and results as have already been noted as being caused 
by atresia hymenalis. 

Etiology. — Congenital atresia results either from an abnor- 
mal development of Midlers ducts or from inflammatory processes 
occurring during foetal life. Acquired atresia most often results 
from a process of sloughing and cicatrization of the vaginal walls. 
This condition may be created by any of the following causes : 
Injuries during childhood ; prolonged and difficult labor ; chemi- 
cal agents locally applied ; impaired vitality, resulting from diph- 
theria or other infectious diseases (scarlet fever, typhus, measles, 
small-pox, cholera, etc.) ; gangrenous vaginitis ; mechanical agen- 
cies, pessary, etc. Atresia may also result from a superficial 
inflammation of the vaginal mucous membrane, resulting in adhe- 
sion of the apposed surfaces. 

Symptoms. — These are first manifest at puberty, and are due 
to the distension of the occluded canal by the accumulated men- 
strual blood. Often the pains are at first only moderate, and are 
supposed to indicate simply the advance of puberty, the menstrual 
molimina. They increase in severity from month to month, until 
they take the form of a violent uterine colic, being of a spasmodic, 
contractive character, owing to the efforts of the uterus to expel 
the accumulation. As the vaginal sac becomes more and more 
distended the suffering becomes more continuous, with shorter 
intervals of relief. Frequently the distended vagina presses upon 
the bladder and rectum, causing more or less disturbance of their 
respective functions. The symptoms gradually increase in inten- 
sity, and, unless relieved by surgical interference or by spontaneous 
rupture of the occluding membrane, they are finally followed by 



94 A TEXT-BOOK OF GYNECOLOGY. 

the results already mentioned under pathology ; or, less often, 
there may result a simple or septic peritonitis, independent of the 
rupture ; or, at times, a hematocele. Again, in still other cases, 
the patient may escape all these results, only to have her life worn 
out by a variety of secondary nervous and cerebral disturbances. 
In those cases in which, from absence of the uterus, or other 
causes, menstruation does not occur, all the above symptoms will 
be absent and the condition may only be discovered on account of 
difficulty in coition. Many cases of this character are recorded, 
and several are reported where for years the sexual act had been 
performed through the dilated urethra, attention finally being 
called to the condition by an incontinence of urine or other vesical 
difficulty. 

Diagnosis. — In atresia hymenalis the bulging forward of the 
membrane from the retained secretion will be readily recognized. 
If the obstruction is higher up, its nature and extent must be de- 
termined by a recto-abdominal examination, or in some instances 
it may be better ascertained by introducing a sound into the blad- 
der and the index finger of the right hand into the rectum. Such 
an examination, aided by the history of the case and the char- 
acteristic monthly occurrence of the symptoms, with their gradually 
increasing intensity, will usually serve to remove all doubt as to 
the nature of the condition. If the vagina be entirely obliterated, 
a hard fibrous cord will be felt extending along its course. If the 
atresia be partial, the cord will be felt only as far as the septum 
extends. If the upper portion of the vagina be distended with 
blood, this will be readily distinguished by a characteristic tense 
elastic feel, like that of a rubber ball, and not infrequently the 
uterus will be detected as a smaller, firmer tumor lying immedi- 
ately above the accumulated blood. 

Prognosis. — In atresia hymenalis the obstruction is readily 
overcome, but the procedure is attended with more danger than 
would naturally be supposed, as septic conditions frequently follow 
and death results. 

In congenital atresia the prospects of being able to establish 
and retain a new vaginal canal are quite unfavorable, yet it has 
often been accomplished. In acquired atresia the prognosis as to 
ultimate results is less favorable in proportion to the extent of the 
adhesions, and can only be said to be good when they are low in 
the vagina. There is always great danger that recontraction will 
follow sooner or later after an operation in spite of the most care- 
ful treatment. Should the blood-sac extend to the uterus, and 
especially if the Fallopian tubes be distended, a sudden evacua- 
tion may permit the entrance of air, and give rise to septic endo- 
metritis; or, uterine contractions may be excited which either force 



DISEASES OF THE VAGINA. 95 

blood through the tubes into the abdominal cavity, or cause a rup- 
ture of the tubes and a consequent hematocele. Dr. Emmett dis- 
sents from this view, but the preponderance of testimony is greatly 
in its favor. He says (1) "The objections to the rapid evacua- 
tions of the retained fluid are entirely theoretical. It would be 
impossible on account of the tenacious character of the fluid, to 
empty the uterus so rapidly as to produce any shock. If such a 
result was likely to follow the rapid evacuation of fluid from the 
uterus, it should at least sometimes occur from the sudden escape 
of the liquor amnii." 

Treatment. — In the outset it should be thoroughly under- 
stood that whatever procedures may be necessary, for the reasons 
already given, the ^evacuation of the imprisoned blood should be 
accomplished with the greatest caution. In all cases, either of 
hymenic or of vaginal atresia, when such a course is possible, the 
contents of the blood-sac should be slowly evacuated by means of 
an aspirator. Only a small quantity should be removed at a time, 
the operation being repeated every two or three days until the sac 
is emptied. If an aspirator cannot be procured, or if for any 
reason its use is inadmissible, resort may be had to puncture by 
means of a small trocar and cannula. After the blood has been 
withdrawn, the action of the aspirator should be reversed, and the 
cavity carefully and repeatedly washed out with tepid carbolized 
water; or, if a trocar and cannula has been used, the carbolized 
water may be gently thrown through the cannula by means of a 
Davidson's syringe. This operation should be performed about 
eight days after the menstrual period, but never during the period. 
If there be an imperforate hymen the opening may then be enlarged 
by means of a crucial incision, or the membrane may be grasped 
with a pair of forceps and a piece snipped out by means of a pair 
of curved scissors. 

The patient should be required to keep her bed for several 
days, and the cavity be washed out in case symptoms of septicae- 
mia develop. 

In vaginal atresia, if the blood cannot be reached through the 
ordinary channels, and the symptoms are urgent, puncture may be 
made through the rectum, or even through the abdominal wall, 
especially if an aspirator needle be used. The next step consists 
in an operation to establish a permanent opening for the escape of 
the menstrual fluids; or, indeed, this operation should, in most 
cases, precede the evacuation of the imprisoned blood, the contrary 
course being pursued only when demanded by the urgency of the 
symptoms. This operation has also been performed in cases of 
vaginal atresia, where there were no evidences of imprisoned blood, 

1) Op. Cit., p. 216. 



96 



A TEXT-BOOK OF GYNECOLOGY. 



but where a normal sized uterus had been discovered, attended by 
a condition of amenorrhea, and also in a few cases where ' ' the ne- 
cessity for sexual intercourse seemed apparent." In cases where 
there is no room for an artificial vagina, the urethra and bladder 
lying immediately upon the rectum, Dr. Fritsch recommends dilat- 
ing the urethra, and producing an artificial vesico-vaginal fistula, so 
; ' that the retained and future menstrual blood flows into the blad- 
der." He does not favor puncture from the rectum "on account 
of the penetration of intestinal gases and consecutive sloughing." 
The details of the ordinary method of operation for vaginal 
atresia, by the formation of an artificial vagina, is as follows: 

The patient having been anaesthetized, and the bladder emp- 
tied, she is placed upon her back, before a good light, her thighs 
being held apart by assistants, one of whom also retracts the labia. 
A sound is then passed into the bladder and held firmly by the 
other assistant, who causes it to press gently downward so that it 
may be felt and followed as a guide by the operator. The index 
finger of the left hand is then introduced into the rectum and used 
as a guide, and also to retract the rectum and prevent its injury. 
If possible, it is better to have this done by an assistant in order 
that the operator may have both hands free. Then, with a pair of 
curved scissors, he makes a transverse incision at the point where 
the septum begins, midway between the urethra and the rectum, 
and introducing the index finger of the right 
hand carefully tears a passage through until the 
cervix is reached, unless there is an accumula- 
tion of blood, in which case this is first evac- 
uated with an aspirator or trocar and cannula, 
according to the rules already laid down. It 
should be observed, after the first incision, that 
the parts are to be torn, and not cut. This is 
much the safer plan in all respects, and it has 
been proved that by this method there is much 
less danger of cicatrization and contraction after 
the operation. After the cervix has been 
reached, the wound is carefully packed with 
strips of lint saturated with carbolized oil. This 
dressing is removed on the following day, and 
a tightly fitting glass plug (Fig. 78) is intro- 
duced into the vagina, secured by a T band- 
age or by tapes, and worn for several weeks, 
or even months, if there appears to be a ten- 
sims' Glass vag- dency to contraction from above, as is often 
the case, especially when the canal has been 
obliterated throughout its entire length. 




Fig. 78 
inal Dilator 



CHAPTER X. 

VAGINITIS. VAGINISMUS. 

Vaginitis. 

Synonyms. — Colpitis. Elythritis. Blennorrhea. 

Definition. — Inflammation of the mueuous membrane, lining 
the vagina. 

Vakieties. — Vaginitis may be either simple, specific, granular, 
or diphtheritic. Winckel describes also the mycotic, gummatous 
or syphilitic, dysenteric, erysipelatous, and vesiculo-herpetic varie- 
ties. 

Simple or specific vaginitis may also be either acute or chronic, 
but the difference between the two clinically is only in degree and 
not in character. So, too, is it difficult, apart from their history, 
to distinguish between the simple and specific varieties. 

Pathology. — In acute vaginitis the mueuous membrane is 
congested, swollen, and its arterioles distended. At first the 
secretion is diminished, later it becomes profuse ; at first it is 
transparent, but it soon becomes cloud}', milky and purulent. The 
epithelium rapidly exfoliates. The papillae are swollen and appear 
as little nodules over more or less of the vaginal surface. Not 
infrequently the parts become cedematous, or the deeper tissues 
become involved and a true plegmonous process is established. 
The character of the secretion is described in the chapter on Leu- 
corrhea. If the vaginitis be specific, due to gonorrheal poison, 
there is little essential difference in the pathology, except that the 
inflammation more often involves the urethra and the lower part 
of the vagina, and the secretion is more abundant, and is more 
purulent in character, owing to suppuration of the glands of Bar- 
tholini, and it is often tinged with blood. 

In granular vaginitis the papillary swelling already referred 
to becomes very widespread, giving the whole surface of the 
vaginal mucous membrane an irregular, uneven appearance, like 
granulations. It appears to be only an aggravation of the papil- 
lary hypertrophy which has already been mentioned as present in 
simple vaginitis, and does not differ essentially from that variety 
of the disease. 

Diphtheritic vaginitis may develop at certain points only, 
where abrasions may have occurred, either from injury or from 
exfoliation of the mucous membrane during simple vaginitis; or 

or 



98 A TEXT-BOOK OF GYNECOLOGY. 

it may involve more or less of the entire vagina, and include the 
vaginal portion of the cervix, the whole vaginal surface being 
covered with diphtheritic membrane. In such cases the swelling 
is very great, almost including the vaginal canal. Schroeder (1) 
says he has seen the cervical mucous membrane so swollen as to 
protrude from the external os, and to the touch appear like a 
mucous polypus as large as a walnut. In the healing process, 
which advances very slowly, considerable stricture may be pro- 
duced, and the vault of the vagina may become adherent to the 
vaginal portion of the cervix. 

In appearance the diphtheritic membrane is homogeneous, and 
is of a gray, whitish, or yellowish-white color. Hilderbrandt has 
described what he called a vaginitis ulcerosa adhesiva, occurring 
in old women when the epithelium is very thin or when it is thrown 
off in patches, and adhesions take place between the adjacent walls, 
especially about the cervix, the vaginal pouch, and sometimes more 
or less of the canal becomes obliterated. As has already been 
stated, the changes in chronic vaginitis differ only in degree from 
those in the acute variety. 

Etiology. — Gonorrhea is the most frequent cause of acute 
vaginitis. Next in order of frequency are the traumatic causes. 
These may be of any description, and include excessive coition ; 
efforts to produce abortion ; efforts to prevent conception ; surgi- 
cal procedures; cauterization; chemical agents; ill-fitting pessaries: 
parturition ; cold water injections ; masturbation, etc. Vaginitis 
may also arise from exposure to cold or moisture ; from dancing 
during menstruation ; from constipation ; from uncleanliness ; from 
retained and putrified secretions, and from irritating discharges 
from the uterus. Vaginitis may also result secondarily from the 
blood states of scrofula, phthisis, diabetes, chlorosis, etc. , and may 
occur in the course of the acute exanthematous and infectious 
diseases — measles, small-pox, typhus, cholera, and dysentery. 
Under the latter conditions we usually find the diphtheritic form, 
and also after parturition. Localized diphtheritic deposits are 
frequently seen about old fistulas, carcinoma, or in ulcerating 
fibroids and polypi, and about ill-fitting pessaries that have been 
worn for a long time. Chronic vaginal catarrh may also be but 
one expression of a general catarrhal state of the system. 

Symptoms. — Acute vaginitis may be ushered in by the usual 
febrile symptoms which attend an initial inflammation elsewhere. 
The following symptoms are usually present : heat and burning 
in the vagina ; aching and sensation of weight in the perineum ; 
frequent desire to urinate, the passage of urine being accompanied 
by a scalding sensation ; profuse, offensive, muco-purulent leucor- 

1) Op. Cit., p. 495. 



VAGINITIS. 99 

rhca ; excoriation and itching of the vulva and surrounding parts. 
In specific vaginitis the symptoms are the same, except that the 
urinary symptoms are more pronounced. In chronic vaginitis 
similar symptoms are present, but in a milder degree. 

Diagnosis. — Examination with the speculum, or by retracting 
the labia, will reveal the inflamed mucous membrane, which is red, 
swollen, painful to the touch and covered more or less with the 
muco-purulent discharge. Usually the history of the case, together 
with the relative intensity of the urinary symptoms, will decide as 
to whether the vaginitis is simple or specific. In some cases a 
microscopical examination of the discharges is necessary for a full 
understanding of the condition. In specific vaginitis the micro- 
scope will show what is termed the gonococcus, in addition to the 
elements found in the simple form. (See chapter on Leucorrhea). 

Prognosis. — This is usually favorable, yet it must be remem- 
bered that acute vaginitis is very liable to recur upon slight provo- 
cation, or run into a chronic state which proves more difficult to 
control. Chronic vaginitis can usually be cured in a comparatively 
short time if the patient can be induced to follow the necessary 
hygienic rules, especially in the practice of strict sexual abstinence. 
In vaginitis resulting from phthisis and other blood states the 
prognosis is less hopeful, and depends entirely upon our ability to 
remove the constitutional dyscrasia. In diphtheritic vaginitis the 
prognosis is grave in proportion to the extent that the system is 
affected by the poison. Sterility may be a result of vaginitis, 
owing to the fatal effects of the acid discharges upon spermatozoa. 

Treatment. — The patient should rest quietly in bed, and use 
hot water injections, with occasional injections of a half -pint of 
tepid water in which has been placed one-half ounce of Hydrastis, 
fluid extract, and the same quantity of glycerine. Calendula or 
Hamamelis will sometimes answer a better purpose than the 
Hydrastis. These may be applied on cotton tampons if desired. 
If the discharges are offensive, carbolic acid should be used, either 
with or without the above remedies. 

Tepid sitz baths are often quite beneficial. Emollient injec- 
tions of flaxseed, oatmeal or slippery elm may be used. In 
severe cases a paste of Fuller s earth, made with water and a little 
glycerine, has been used with success. Fill the vagina with this 
mixture, and also apply it over the external parts. After it has 
become dry wash out the vagina with a syringe, and use a fresh 
supply. 

In diphtheritic vaginitis a wash of permanganate of potash or 
of diluted alcohol is most beneficial. A careful selection and 
administration of the indicated remedy is always essential. 

The remedies most often used are : 



100 A TEXT-BOOK OF GYNECOLOGY. 

Acute Vaginitis. — Aconite, Arsenicum, Cannabis sat., Bel- 
ladonna, Cantharides, Kreasote, Mercurius, Nitric acid, and Rhus 
tox. 

Diphtheritic Vaginitis. — Apis, Arsenicum, Belladonna, 
Lachesis, Mercuriusi odium, Nitric acid. 

Chronic Vaginitis. — Arsenicum, Calcarea carb. , Cantharides^ 
Carbo veg., Conium, Graphites, Kreasote, Ferrum, Hydrastis, 
Iodium, Mercurius, Phytolacca, Pulsatilla, Sepia, Silicea, Sulphur. 

The chief indications for the use of each of these remedies are 
sufficiently given in the chapter on Leucorrhea, to which the 
reader is referred. 

Vaginismus. 

Definition. — An excessive sensitiveness about the hymen 
and vaginal orifice, so that any contact or irritation gives rise to 
spasmodic contraction of the sphincter muscles of the vagina. 

Pathology. — This condition is supposed to be purely nervous 
in its character, and not necessarily accompanied by any patholog- 
ical changes, though these are sometimes found in connection with 
it, and may have occurred as a result of the continued nervous 
irritation, or of the efforts made to overcome the spasmodic con- 
striction ; or, they may have been present primarily, and been 
the original cause of the trouble. There is usually observed red- 
ness, erosions, swelling of the follicles, and papillary excrescences 
at the navicular fossa. In most cases the hymen or its remains 
are found, being usually thick, large and resistant to the touch. 
According to Sims, the seat of the disease is in the base of the 
hymen, or at the upper margin, nearest the urethral commissure. 

Etiology. — Undoubtedly the most common cause of vagi- 
nismus is repeated and unsuccessful attempts at coitus. This may 
be due to awkwardness on the part of the man, or to some obstacle 
on the part of the woman, such as a small vulvar orifice, or a rigid,, 
resisting hymen ; or, the male organ may be disproportionately 
large. The condition may be also induced by disease of the geni- 
tals ; endometritis ; lacerated cervix ; displacements ; ovarian 
irritation ; vaginitis ; vulvitis ; fissure ; herpes or eczema of the 
vulva ; an inflamed hymen, or hyperesthesia of the remains of 
the hymen ; hemorrhoids ; fissures in the rectum ; pin-worms ; 
irritable caruncle of the meatus. 

Vaginismus may also be present in patients of a nervous and 
sensitive temperament where none of these causes can be discovered, 
the condition being undoubtedly due to purely nervous causes. 
Probably mental emotions — excitement and fear, especially in 
ill-mated couples — have much to do with producing vaginismus, 
and no doubt hysteria often plays an important part in its- 
causation. 



VAGINISMUS. 101 

Symptoms. — The chief symptom is excessive pain on attempt 
at sexual intercourse, the slightest contact causing spasms of the 
muscles, and, according to Sims, there is often a general muscular 
agitation, intermittent rigors, and a most deplorable state, amount- 
ing even to agony and terror, attempts at intercourse being 
sometimes followed by convulsions and syncope. The very thought 
of intercourse, or of a physical examination, will often throw the 
patient into a state of violent excitement and nervous trepidation. 

Diagnosis. — Inspection of the genitals may reveal one of the 
causative conditions already mentioned, and upon touching the 
parts the patient shrinks from the finger and complains of agoniz- 
ing pain, the muscles being at once in a state of violent contraction. 
If no cause is readily discovered, the patient should be placed under 
an anaesthetic and subjected to a careful and thorough examination. 
This, with the history of the case, will undoubtedly settle the 
diagnosis. Distinction should be made between vaginismus and 
those cases of dyspareunia which are unattended with spasm. 
Cases are recorded in which an examination could readily be made, 
and a large sized speculum be introduced, without causing pain or 
spasm, yet these were induced upon the slightest attempt at coitus. 
Such cases are undoubtedly of purely nervous origin. 

Prognosis. — If a local cause can be found, and one which 
can be removed, as is fortunately often the case, the prognosis is 
good. Cases of purely nervous origin are, like hysteria itself, 
very difficult to cure. Spontaneous cures seldom occur, in the 
absence of treatment the condition lasting indefinitely. 

Treatment. — This consists in the removal of the local cause 
if such can be ascertained, and the administration of the appro- 
priate remedy for the nervous condition that may be present, 
whether that be of primary or secondary origin. In most cases of 
a severe character, in which an irritable hymen is present, Sims' 
operation is probably the best treatment yet devised. His plan is 
as follows : Place the patient on her back, as for lithotomy; pass 
the index and middle fingers of the left hand into the vagina; 
separate the walls laterally, so as to dilate the vagina as widely as 
possible, putting the fourchette on the stretch; then, with a com- 
mon scalpel, make a deep cut through the vaginal tissue on one 
side of the mesial line, bringing it from above downward, and ter- 
minating at the raphe of the perineum. This cut forms one side 
of a Y. Then pass the knife again into the vagina, still dilating 
with the fingers as before, and cut in like maimer on the opposite 
side, from above downward, uniting the two incisions at or near 
the raphe, and prolonging them quite to the perineal integument. 
Each cut will be about two inches long, that is, half an inch or 
more above the edge of the sphincter, half an inch over its fibres, 



102 A TEXT-BOOK OF GYNECOLOGY. 

and an inch from its lower edge to the perineal raphe. He then 
continues the treatment by having the patient wear, for several 
weeks, one or two hours night and morning, his glass dilator (Fig. 
78). When the vaginismus is evidently due to remnants of the 
hymen causing irritation, it may sometimes be necessary only to 
snip these off with a pair of scissors, but ordinarily Sims' opera- 
tion is required. 

A bloodless and less severe method, especially applicable where 
no local lesion can be found, is the forcible dilatation of the parts 
with the fingers or an appropriate instrument. The patient is 
anaesthetized, and the parts stretched until the muscular fibre can 
be felt yielding to the traction. The glass dilator is then intro- 
duced and worn until all tendency to spasm is overcome. In mild 
cases the vaginal dilator worn a few hours each day may remove 
all the trouble. The size of the dilator should be gradually in- 
creased. Coitus under an anaesthetic has been practiced, with the 
hope of securing conception, but the plan is not to be recommend- 
ed. Application of cocoa butter, cosmoline or Belladonna oint- 
ment are sometimes beneficial. Whatever local measures may be 
employed the hygienic care of the patient, and her constitutional 
treatment, should not be neglected. Coition should be entirely pro- 
scribed during the course of treatment, and for several weeks 
after, even if it be necessary for the patient to leave home tempo- 
rarily for that purpose. Indeed, a change of scenery is often in 
itself of great benefit in these cases. Daily sitz-baths should be 
used, and the patient should be advised to take as much exercise 
in the open air as is possible without carrying it to the point of 
actual fatigue. In many cases a careful observance of these rules, 
together with the administration of the indicated remedy, will 
effect a cure. As a rule, therapeutic indications are based upon the 
general symptoms of the patient rather than upon the local con- 
ditions. The remedies most often employed are Arnica, Bella- 
donna, Gelsemium, Cuprum, Caulophyllum, Hyoscyamus, Igna- 
tia, Kali brom., Macrotin, Nux vomica, Mercurius, Platina, Hama- 
melis, Plumbum, Pulsatilla, Thuja, Zincum. 



CHAPTER XI. 

PROLAPSUS VAGINA. CYSTOCELE. RECTOCELE. ENTEROCELE. 

Prolapsus Vagina. 

Definition. — A downward protrusion of the vaginal walls. 
This condition is usually secondary to and associated with pro- 
lapsus uteri, or it may occur in connection with cystocele, ovaricele, 
enterocele or rectocele, yet it may exist as a primary displacement, 
independent of any of these conditions, and as such it w T ill here be 
briefly considered. 

Etiology and Pathology. — Prolapsus of the vagina occurs 
from relaxation and atony of the vaginal walls, and usually results, 
as do all the varieties of vaginal hernia mentioned above, from 
retarded involution of the vagina after parturition. There may 
also be laceration of the perineum, with a torn or enfeebled condi- 
tion of the vaginal sphincters, and sub-involution of the uterus, 
thus weakening the perineal supports and lessening the power of 
resistance to the increased weight and pressure from above, caused 
by the enlarged and congested uterus, which crowds down upon 
the relaxed vaginal walls and causes them to be displaced. Pro- 
lapsus may also occur from senile atrophy of the vaginal walls, and 
from the continued pressure or traction of tumors. 

The pathological changes consequent upon a prolapsus of the 
vagina are thus described by Winckel (1) : u When a portion of 
the vagina has passed through the introitus and remains exposed 
to the air and other irritants for any time, the mucous membrane 
becomes paler, firmer, and its folds are effaced; it appears like 
cuticle, from the transformation of its epithelium, and both mucous 
membrane and the tissue beneath become infiltrated, ceclematous 
and passively congested. Associated with the above changes are 
found hyperplasia and hypertrophy of the muscular layers. Vari- 
cosities are often produced by stasis in the vessels. In elderly 
patients the walls of the inverted part are very much thinned by 
the disappearance of the para-vaginal adipose tissue, and look 
smooth and glossy. There may also be loss of substance in the 
more dependent parts near the perineum, associated with slight 
swelling of the adjacent parts, the wound having a secreting sur- 
face with reddened edges. Such spots are to be regarded as 



1) Diseases of Women. Parvin, p. 126. 

103 



104 A TEXT-BOOK OF GYNECOLOGY. 

decubitus, since they are subjected to pressure and irritation in 
walking, sitting and lying; subsequently they become enlarged 
and unhealthy-looking from dribbling of urine and difficulty in 
maintaining cleanliness." 

Symptoms. — These are usually a sensation of bearing down, 
fullness and heat in the vagina, sometimes extending to the vulva, 
together with more or less discomfort and uneasiness in the locality 
when walking or during any muscular exertion. Physical exam- 
ination will reveal an elastic, globular tumor between the labia, the 
mucous covering of which is sometimes excoriated and ulcerated, 
or, in cases of very long standing, it may appear smooth, shiny 
and tough, and be covered with pavement epithelium. Simple pro- 
lapsus, not involving hernia of any of the pelvic organs, rarely 
occurs, and when it does it is usually confined to the posterior wall, 
which peels off from the rectum, without causing rectocele. 

The treatment of simple prolapsus of the vagina is practically 
the same as when complicated with some form of vaginal hernia, 
and will be considered later. 

Cystocele. 

Synonyms. — Cystocele vaginalis; vesico-vaginal hernia. 

Definition. — A prolapsus of the anterior vaginal wall, accom- 
panied by a descent of the posterior wall of the bladder, the two 
being closely adherent to each other. 

Pathology. — The lower portion of the bladder is pushed 
downward and forward under the urethra, forming a pouch, 
which becomes filled with urine. This pouch usually is so small 
that it remains behind the symphysis pubis, but it may form a 
tumor as large as a child's head, and lie external to the vulva. The 
urine in the pouch cannot be evacuated during micturition, and 
becomes decomposed, giving rise to vesical catarrh. The fermen- 
tation accompanying this catarrh may cause the formation of phos- 
phatic concretions, calculi having frequently been found in the 
bladder of persons suffering with cystocele. 

Symptoms. — A frequent desire to urinate, with dysuria, are 
the chief symptoms, though dysuria is not invariably present. 
There is usually more or less ropy mucus in the urine. 

Diagnosis. — Physical examination will show a yielding, elas- 
tic tumor, which is easily reduced, but reappears at once upon 
slight straining of the abdominal muscles. If the diagnosis is in 
doubt, a catheter may be passed into the bladder with its point 
downward, and the end will be felt protruding against the walls 
of the pouch. 

Prognosis. — The prognosis is usually favorable, proper sur- 
gical measures being quite effective in producing a cure. If a 



RECTOCELE—ENTEROCELE. 105 

cystocele be neglected, it may finally give rise to disease of the 
kidneys or wasting of the ureters, which may result fatally. 

Rectocele. 

Synonyms. — Rectocele vaginalis; recto- vaginal hernia. 

Definition. — A prolapsus of the posterior vaginal wall, ac- 
companied by descent of the anterior wall of the rectum, the two 
being loosely adherent to each other. 

Pathology. — The inward and downward protrusion of the 
rectum forms a pouch, which becomes filled with feces, creating a 
tumor as large as the fist or larger. The tumor is usually flabby, 
and easily reduced, but is occasionally firm and hard, from im- 
pacted scybala. The condition is analogous to that of cystocele, 
but is of much rarer occurrence, owing to the loose attachments 
between the vagina and rectum, allowing a more ready separation 
when prolapsus of the vagina takes place. 

Etiology. — Rectocele, when not associated with and caused 
by prolapsus of the uterus, usually results either from laceration 
of the perineum or from the pressure of scybala in the rectum, or, 
more often, from the loosening and distension of the vaginal walls 
by pregnancy and labor. 

Symptoms. — The symptoms arc those which result from the 
accumulated hardened feces, irritation and inflammation of the 
mucous membrane, mucous discharges, tenesmus and constipation. 
Hemorrhoids frequently result from the interference with the 
portal circulation. Sometimes there is loss of appetite, pain in 
the abdomen, nausea and deranged digestion. 

Diagnosis. — The tumor may be seen projecting from the 
posterior vaginal wall, sometimes outside the vaginal outlet. It is 
usually soft, but sometimes quite solid from the presence of har- 
dened feces. The finger should be passed through the anus into 
the pouch, and the relations of the rectal and vaginal wall thus 
determined. Careful palpation will serve to differentiate from an 
abscess of cyst. 

Enterocele. 

Synonyms. — Enterocele vaginalis; cntero-vaginal hernia. 

Definition. — A descent of the peritoneum and a portion of 
the small intestines into the vaginal canal, sometimes reaching the 
perineum. 

Pathology. — Enterocele may be anterior or posterior. In 
the former the intestine is forced down between the posterior 
aspect of the bladder and the anterior vaginal wall. This form is 
extremely rare. Usually the intestines descend between the 
anterior rectal and posterior vaginal wall. A loop of the intestine 



106 A TEXT-BOOK OF GYNECOLOGY. 

having once descended into Douglas' cul-de-sac cannot escape; 
gradually stretching the surrounding tissues, it gradually descends, 
pushing the posterior vaginal wall before it. If the entrance to 
Douglas' cul-de-sac be very narrow, strangulation of the hernia may 
occur, but the chief danger arises from strangulation or laceration 
during childbirth. Did none of these accidents happen, enterocele 
might exist for a long time without producing any evil results. 

Diagnosis. — The diagnosis of enterocele is important in order 
to avoid the mistake of puncturing it for a supposed vaginal tumor. 
On examination, a bulging mass is found in the vagina, having a 
soft elastic feel, as if filled with air, yielding a tympanitic sound 
on percussion, and having a peristaltic movement. The uterus is 
in normal position, which will distinguish it from prolapsed uteri, 
and rectal examination will serve to differentiate it from rectocele. 
If any doubt remain as to the character of the tumor, a small 
aspirator needle will enable the physician to settle the question. 

The treatment of the several conditions described will be 
given in the next chapter. 



CHAPTER XII. 

TREATMENT OF PROLAPSUS AND HERNIA OF THE VAGINA. 
1. Perineorrhaphy. 2. Elytrorrhaphy. 3. Episiorrhaphy. 

Ix recent cases the patient should be placed in the knee-chest 
position and the parts restored to their normal place, after which 
the patient should lie upon her back for several days, with the 
hips elevated. If there is a tendency to return upon assuming 
the upright posture, a cotton tampon may be inserted, or a properly 
fitting ring or Hodge pessary may be adjusted. Allopathic authori- 
ties recommend local astringents, such as tannin, alum, or white- 
oak bark, either by injection or by saturated tampons. Vaginal 
prolapsus or hernia usually comes on slowly, and does not readily 
yield to treatment. In such cases the patient's general health 
should be improved by the observance of proper hygienic rules, 
and the constitutional remedies carefully selected according to the 
symptoms of each individual case. The remedies most often indi- 
cated are : Arsenicum, Calcarea carb., Cinchona, Ferrum, Helo- 
nias, Nux vomica, and Sepia. The parts should be frequently 
bathed in cold water, and the bladder and rectum frequently and 
regularly evacuated. Valuable aid is sometimes secured by using 
an external abdominal supporter with a perineal band, or by wear- 
ing a properly constructed pessary, or an inflated rubber bag. 

A radical cure is seldom secured except by surgical proced- 
ures, which are, as a rule, comparatively simple in their character 
and very satisfactory in their results. The following are the vari- 
eties of surgical operations usually practiced: — 

1. Perineorrhaphy — repair of the perineum, 

2. Elytrorrhaphy — diminishing the calibre of the vagina. 

3. Episiorrhaphy — uniting the labia majora. 

The two operations first named are sometimes performed upon 
the same patient, constituting Elytro-perineorrhaphy. The details 
of the various operations are as follows: — 

1. Perineorrhaphy. — Aside from its value in cases of vagi- 
nal prolapse and hernia resulting from a lacerated perineum, this 
operation is one of the most important in gynecology to the gen- 
eral practitioner, owing to the wide etiological influences of the 
condition it is designed to remedy. The operation may be cither 
primary or secondary ; that is, it may be performed immediately 

107 



108 



A TEXT-BOOK OF GYNECOLOGY. 



after the perineal tear has occurred, or after cicatrization has taken 
place. The primary operation, except as a prophylactic measure, 
has nothing to do with the treatment of the various forms of pel- 
vic hernia, and properly belongs to works on obstetrics, but for 
convenience it will be briefly. described in this connection. 

There exists considerable difference of opinion as to the ad- 
visability of operating immediately after delivery, but the majority 
of authorities agree with Scanzoni that ' 4 The operation should be 
performed just after the delivery, because it is more likely that the 
bleeding lips of the wound will then unite, and because vivifica- 
tion of the edges not being necessary, the procedure is simpler and 
less dangerous." 

In cases where the sphincter ani and the recto-vaginal wall are 
seriously implicated, it is better to postpone the operation until the 
patient has otherwise entirely recovered from her confinement, but 
when the sphincter ani only is involved, the operation should not 
be deferred. The reason that the primary operation is often unsuc- 
cessful is doubtless due to the fact that it is frequently performed 
in a hasty and careless maimer, and often by an inexperienced op- 
erator, and also because the lochial discharges and urine are liable 
to enter the wound and prevent adhesion. 

Primary Operation. — The primary operation is performed 
as follows: The placenta having been delivered, the patient is 
placed upon her back with her hips well over' the edge of the bed. 




Fig. 79. — Peaslee's Perineum Needle. 




Fig. 80. — Goodell's Perineum Needle. 




Fig. 81. — Skeen's Perineum Needle. 



The parts are carefully cleansed with warm calendula water and any 
shreddy portions removed with the scissors. Anaesthesia is not 
usually required. I prefer Peaslee's needle and the silver suture, 
The first suture should be placed at the lower angle of the wound, 



PERINEORRHAPHY. 109 

the needle entering about half an inch from the rupture makes the 
entire circuit of the wound and is brought out at the same distance 
from the rupture on the opposite side. Sutures are similarly 
placed about half an inch apart, the last suture being made stronger 
by causing it to traverse a portion of undenuded tissue before 
completing the circuit. If the rectum is involved, catgut sutures 
should be employed for that part, as they obviate the necessity of 
future removal. The wound should be protected from the dis- 
charges as much as possible, and the urine drawn with a catheter 
every four or six hours. The stitches should be removed on the 
eighth or ninth day. 

It is not inappropriate to here state that in recent cases union 
may sometimes be secured without an operation, though I must 
confess that I have never been very successful in such efforts. In 
cases where the laceration is not extensive, or, where the presence 
of an epidemic, or other circumstance, contraindicates operative 
measures, it may be best to make the attempt. Dr. Ludlam says, 
(1): " In such cases my own practice has been to cleanse thor- 
oughly with warm Calendula water, carefully removing all clots, 
bits of fat and shreds, and then to mold the edges as carefully as 
possible so as to bring the tegumentary perineum into its proper 
position. Then I place a firm compress that has been moistened 
with a mixture of equal parts of Calendula or of Hamamelis, gly- 
cerine and warm water, against the perineum, and while the limbs 
are flexed, put two or three adhesive straps across the buttock to 
keep the compress in position. This adjustment of the parts 
should be made with the patient lying upon her side. The com- 
press may be freshened two or three times in twenty-four hours, 
and weak injections of Calendula water may be given per vaginum 
once or twice daily until the wound is healed. The knees should 
be tied together, but not tightly, for the first forty-eight hours. 
The bowels should be let alone, the patient should lie upon 
her side, and the urine should be taken with the catheter. I 
have practiced this simple plan of treatment for almost thirty 
years, and am confident that in a great majority of cases it is quite 
sufficient. It may sometimes be supplemented by the use of serre- 
fines, which if they are the right kind and properly adjusted, will 
keep the edges of the wound from slipping before they have 
healed. If the patient is very nervous and apprehensive, she need 
not know that they have been applied, and the compress can be 
used at the same time." 

2. Secondary Operation. — This operation consists in a 
vivification of the lips of the wound, and their approximation by 
sutures. It should never be performed until the patient has 

1) Diseases of Women, 6th ed., p. 897. 



110 A TEXT-BOOK OF GYNECOLOGY. 

entirely recovered from the effects of parturition, three months 
being the shortest time that should be allowed for this purpose. 
The operation may be required only to repair the perineal body, 
or it may be necessary also to operate for a rupture of the sphinc- 
ter ani and more or less of the recto-vaginal wall. Ordinarily 
if only the sphincter ani is involved the entire rent may be re- 
paired at one operation, but if the recto-vaginal septum be 
involved to any extent it is better first to restore the integrity of 
these parts, deferring the perineal operation until the wound thus 
created has entirely healed. 

The patient should prepare herself for the operation by using 
the hot water douche daily for a week previous, and if any con- 
siderable leucorrhea be present, she should also use daily an injec- 
tion of equal parts of fluid Hydrastis and fluid Calendula in a pint 
of warm water. If necessary, the bowels should be opened by an 
enema a few hours before the operation. Four assistants are de- 
sirable, but three will answer the purpose. One of these should 
administer the anaesthetic, two support the knees of the patient, 
while the fourth can hand instruments, wash sponges, and perform 
such other services as the operator may require. 

The patient should be placed upon her back on a firm table, 
facing a good light, and the anaesthetic administered. One assistant 
stands on either side, facing the operator, and with one arm keeps 
the knees of the patient well abducted, while with the other hand 
they hold open the labia, taking care to keep them exactly in the 
same position on each side, and making no irregular traction in any 
direction. Retractors are more convenient than the fingers for this 
purpose. If the sphincter ani is torn, this must first receive atten- 
tion. The opposite edges are carefully cut away with a long- 
handled bistoury or scissors, the whole of one side being re- 




Fig. 82. — Jenk's Perineum Scissors, 



moved in one strip, if possible., so that no islets are left behind. 
It is important that the cicatrix at the angle of the tear be re- 
moved, and in order to insure apposition of the raw edges at the 
angle, it is best to extend the laceration about an eighth of an 
inch. 

This having been accomplished, the next step is to introduce 
the sutures. If the perineal operation is to be performed at the 
same time, and the sutures are interrupted, it is best to use catgut, 



PERINE ORRHAPHY. 



Ill 



otherwise silver wire will answer the best purpose. If the rent in 
the recto-vaginal septum is extensive, interrupted sutures should 
be placed about one-fifth of an inch apart, being introduced by 
means of a needle with a short lateral curve (Fig. 83), such as are 




} i£mffiQ^ffi&8fi®& 



wmunmsas* 
Fig. 83. — Needle with short lateral curve. 



used in vaginal fistulas. Catgut sutures are tied in the vagina and 
cut short; silver wire sutures are twisted and cut about half an 
inch from the wound. Dr. Thomas very plainly illustrates why a 
different method should be adopted in the introduction of the 
sutures, in order to secure "complete union of the ends of the 
severed muscle and complete closure of the rent in the bowel," so 
that not only will the rent in the genital fissure be closed, but the 
incontinence of feces and gases be avoided. 

This method was first introduced and practically demonstrated 
by Dr. Emmett (1), and is fully elaborated in his valuable text- 
book (2). It consists in introducing the first needle as low down 
as the lower edge of the anus, pressing it upward through the 
recto-vaginal septum, completely encircling the rectal rent and 
returning bringing it out opposite the point of introduction on the 
other side of the anus. The index finger of the left hand should 
be introduced into the rectum to serve as a guide. ' ' As the point 
of the needle punctures the skin in its exit, the finger may be with- 
drawn from the rectum to aid the passage of the needle. This can 
be done by the counter-pressure of a blunt hook, or by sliding 
back the tissues sufficiently with the fingers for the needle to be 
seized by the forceps and drawn through. The second suture is 
to be introduced just outside of the end of the muscle, and in the 
same plane with the divided rectal edge of the laceration. The 
third suture is to secure the vaginal edge of the laceration. It 
should be made to include the tissues liberally, and to sweep 
around the angle of the laceration at some distance beyond the 
course of the first and second sutures. This is necessary because 



1) Medical Record, March 15, 1873. 

2) Priri. and Prac. of Gynecology, p. 



112 A TEXT-BOOK OF GYNECOLOGY. 

this suture is the one most liable to cut through the recto-vaginal 
septum and leave a fistula. The other sutures are to be intro- 
duced as in a case of simple laceration. 

"It is necessary to secure first the lowest suture. This 
is done by seizing the ends of the wire at the proper distance, so 
that the index finger may be used to slide the tissues firmly down 
on the suture, as moderate traction on the wire is made at the same 
time with the hands. The suture is then secured without relaxing 
the traction, by several half turns made on reversing the position 
of the hands from one side to the other. Each suture is thus in 
turn secured from below upward. Experience alone can indicate 
the proper amount of tension to be made, and success will depend, 
to a great degree, upon this part of the manoeuvre. The parts 
should be brought just into apposition, and no more, for in a few 
hours there will be sufficient swelling to force the tissues into close 
contact. If the sutures have been twisted too tightly, and espe- 
cially if they have been introduced in too superficial a manner, they 
will cut out from behind forward. This will leave a fistula, or the 




Fig. 84.— Surface denuded in complete perineal rupture, and first two 
sutures in position. 

tissues in front will become sufficiently strangulated to set up some 
inflammatory action, resulting afterward in a labial abscess." 

The twisted sutures are to be left several inches long, and 
are to be secured by the same method as when used for simple 
laceration of the perineum. 

Fig. 84 will illustrate the position of the first two sutures and 



PERINE ORRHAPHY. 



113 



explain why it is, as Dr. Emmett says (1) "that a suture that 
takes this course, like the string at the mouth of a bag, puckers 
the open parts, draws them into apposition, and controls the action 
of the sphincter. The two conditions which we have most to fear 
as sources of failure after this operation are, first, recto-vaginal 
fistula, and, second, non-union of the sphincter. This method, to 
a great extent, secures us against both." 

The repair of the perineum must now receive attention. The 
secondary operation differs from the primary in the fact that the 
surfaces of the torn perineum have become cicatrized, and require 
to be freshened before the sutures are introduced. This denuda- 
tion should extend, as nearly as possible, over and a trifle beyond 
the area of the torn perineal walls. Fig. 85 represents the parts 




Fig. 85. — Perineum freshened, with sutures introduced. 

after denudation, with sutures inserted. This should be accom- 
plished in the following manner : Sims' speculum having been in- 
troduced under the symphysis pubis, and the anterior wall lifted, 
an incision is made directly up the middle of the posterior junction 
of the laceration for about an inch and a half. This marks the 
base of the two triangular denudations to be made. Next make a 
lateral incision each way from the upper end of the mesial incision, 
forward, along and just beyond the edges of the torn surfaces to 
the labium majus, and another from this point on each side back 
to the very end of the vesical incision. The triangular flaps thus 
marked out are then dissected from behind forward, either with a 
pair of fine scissors or with the knife. Should the denudation be 

1) Op. Cit., p. 140. 



114 A TEXT-BOOK OF GYNECOLOGY. 

commenced in front, the backward flow of blood will greatly 
obscure subsequent progress. The flaps should be dissected off 
thicker at the sides than over the rectal wall, where they should 
be made as thin as possible. Hemorrhage is usually easily con- 
trolled by pressure or torsion, or by the use of hot water, ligation 
being seldom necessary. Search is now made for any undenuded 
points that may remain, which are caught up with the tenaculum 
and cut away. After waiting for a few minutes to be certain that 
all hemorrhage has ceased, we are ready to proceed with the second 
part of the operation, which consists in the introduction of silver- 
wire sutures. 

Before proceeding farther, I will briefly refer to a new plan of 
denudation, first proposed by Dr. Jenks, of Chicago (1), and which 
has since been endorsed and successfully practiced by Emmett, 
Albert Smith, Thornburn, and other eminent gynecologists. It 
consists in first making a small incision with fine scissors, about 
the centre of the lower border of the proposed raw surface. 
Through this both blades are insinuated, below and parallel to the 
mucous surface, and its separation is now performed subcutane- 
ously by repeated snippings. Discoloration of the surface clearly 
marks the route the scissors have taken, but there is no external 
hemorrhage, except a few drops from the opening, and the process 
is rapid. When the whole required surface is thus separated from 
its attachments, and clearly indicated to the eye, the flaps are cut 
away on each side by scissors, with perfect regularity of outline, 
and there is no necessity for searching for islets of mucous tissues 
not separated. 

I would also call attention to a modification of the usual oper- 
ation sometimes practiced, in which the lateral incision from the 
upper end of the mesial incision is not made, the dissected flaps 
not being removed, but utilized by turning them forward to the 
vagina, bringing them in apposition and uniting them by sutures 
(Figs. 86, 87), thus giving increased strength and thickness to 
the repaired perineum. This is sometimes known as the triangular 
flap operation. 

A variety of needles, both straight and curved, are used 
for the introduction of the sutures. I prefer a round curved 
needle. There are several kinds of perineal needles in fixed handles 
which have their advantage. In introducing the suture a finger 
is placed in the rectum to act as a guide to the needle, which 
should never be allowed to penetrate the rectal wall. The needle 
may be armed directly with the silver wire, but it is better first to 
place a loop of silk thread, about eight or ten inches long, in the 



1) Am. Journal of Obstetrics, April, 1887. 



PEBINE ORRHAPHZ Y. 



115 



needle, and to this may be attached the silver wire, either before 
or after the silk has been drawn through the wound. 

The first suture is passed at a point about level with the mar- 
anus, and passing across beneath the tissue over the 
rectum it emerges at a corresponding point on the opposite side, 
its exit being aided by counter-pressure made with a blunt hook. 
The remaining sutures are introduced in a similar manner, about 



gin of the 





Fig. 86. — Lines of incision in the 
triangular flap operation. (Hart 
and Barbour.) a, 6, labial inci- 
sion; c, b, median line incision 
passing to posterior vaginal wall: 
a b c, flap to be raised. 



Fig. 87. — Flaps raised and sutures 
passed in same operation. (Hart 
and Barbour.) 



one-third of an inch apart. They should all be embedded beneath 
the tissue, so that no part of them is visible in the vagina. This 
is not the case, however, with the last or upper suture, which runs 
across the orifice in plain view. On the contrary, some authorities 
recommend having the middle of each suture exposed, only em- 
bedding the last suture, but I prefer the former method (Fig. 88). 
The sutures all having been placed, their ends are gathered up and 
flaps carefully drawn in apposition, to see if they are adjusted 
properly. If so, the parts are carefully cleansed with calendula 
water, after which the sutures are twisted, beginning with the 
lower one, being careful, as each suture is tightened, to see that the 
flaps are accurately adjusted. Superficial sutures of catgut may 
then be passed whenever they are requii ed in order to more nicely 
approximate the cutaneous surfaces. Perforated shot, tubing, or 
quills, through which the sutures are passed, are often used to 



116 A TEXT-BOOK OF GYNECOLOGY. 

prevent the sutures cutting into the external tissues. I have never 
found them necessary, and agree with Dr. Ludlam that they ' ' are 
of no especial advantage." After the sutures are all twisted, they 
are cut short and turned at right angles. 

The after-treatment consists in putting the patient in bed, 
where she is instructed to lie quietly upon her back, especially 
during the first forty-eight hours. The knees are tied together 




Fig. 88. — Shows surface denuded, and sutures in position. 

and the urine is drawn by catheter every four or five hours. No 
dressings are required during the first two days. After that the 
vagina may be carefully syringed out twice a day with tepid 
calendula water, and the wound dressed with absorbent cotton 
saturated with calendula and glycerine, or calendula cerate may be 
directly applied. This may be kept up until the sutures are 
removed, which should be done on the eighth or ninth day, unless 
menstruation has intervened, in which case they may be left a few 
days longer. Some operators always leave the upper suture until 
the tenth or twelfth day. The diet should be nourishing, but mild 
and easily digested, consisting mostly of soups, broths, gruels, and 
the like. The bowels should, if necessary, be kept loose by means 
of appropriate mineral waters. Cathartics should not be admin- 
istered. If union has taken place, the patient can sit up in about 
two weeks from the date of the operation, and assume her ordinary 
duties the week after, but should for some time be careful not 
unnecessarily to strain or stretch the parts. 



ELYTEORRHAPHY. 117 

2. Elytrorrhaphy. — This operation consists in making a 
triangular raw surface on the vaginal wall, as shown in Fig. 89, 
and bringing the opposite sides together by means of sutures, thus 
reducing the size of the vagina. In cystocele the operation must 
be made upon the anterior vaginal wall, and in prolapsus of the 
posterior vaginal wall, and in rectocele and enterocele, upon 
the posterior vaginal wall. 

Sims' method of operating consists in first putting the patient 
under the influence of an anaesthetic, placing her upon a table in 
the semi-prone position, and introducing a Sims' speculum. A 
curved sound, with forked tenaculum points, is then fixed in the 
cervix uteri and made to cause a fold in the anterior vaginal wall. 




Fig. 89. — To show raw surface as made by Sims {Marion Sims). 

These folds are then brought together by tenacula in order to as- 
certain where the denudation is to be made. A tenaculum is then 
introduced into the mucous membrane at a point near the urethra, 
and the surface pared by means of curved scissors along the line 
previously decided upon, to a point opposite the cervix. The same 
course is followed in the other fold, after which, the sound having 
been removed and the cervix pulled down by a small tenaculum, 
two transverse denudations are made, one from each upper point 
of the previous denudation, running inward until they nearly 
reach each other, as shown in Fig. 89. Dr. Emmett found that 
this method left a pouch which was sometimes entered by the cer- 
vix, and he improved the operation by carrying the transverse 



118 



A TEXT-BOOK OF GYNECOLOGY. 



denudation entirely across from one upper arm of the triangle to 
the other (Fig. 90). Silver sutures are then placed in the same 
manner as in vesico-vaginal fistula, beginning at the base of the 
triangle and continuing upward. The patient is'then placed in 
bed and kept quiet for two or three weeks, the sutures being care- 
fully removed in about twelve or fourteen days. Hegar holds 
(1) that union does not often take place uniformly at the broad 




Fig. 90. — Emmett's operation of Elytrorrkaphy. 

end. He says that both Sims and Emmett "believed that this 
operation alone would cure even considerable vaginal and uterine 
prolapse, but this is impossible." 

Hegar recommends the simple excision of a uniform longitu- 
dinal fold, attaching no importance to the special shape of the 
denudation. He says that "in this way the operation may be per- 
formed very rapidly and almost without hemorrhage." A longi- 
tudinal fold is first formed in the anterior vaginal wall by means 
of two or three volsellas. The upper one is placed about one-third 
of an inch from the anterior lip, and the lower one about three- 
fifths of an inch from the meatus. By pulling on these instru- 
ments the fold is raised, and a clamp is applied in a longitudinal 
direction, nearer to the ridge than to the base of the fold. Sutures 
are then applied at a little distance below the clamp, one-third of 
an inch apart. The fold is then cut away between the clamp and 

1) Handbook of Gen. and Op. Gyn. W. Wood & Co., p. 268. 



EL YTR ORRHAPHY. 1 1 9 

the sutures, and the latter tied, accurate closure of the wound 
being accomplished by means of superficial sutures. After coap- 
tation the wound is pressed together from the sides in order to 
ascertain whether any blood has been extravasated. If this has 
occurred in any part and blood escapes between the sutures, the 
part is enclosed in a deep ligature. Great care should be taken 
that the wall of the bladder be not included in the fold, and excised. 
If on account of thinness of the vaginal Avails this cannot be 
avoided, it is better to adopt Sims 1 method of operation. I think 
Hegars method is especially useful in operations upon the poste- 
rior wall, though here it may open Douglas 1 cul-de-sac, which is to 
be avoided if possible. 

Thomas' method of operation offers some advantages, and is 
the one I prefer in most cases. It may be performed upon either 
one, or upon both vaginal walls, in two successive operations, and 
with the uterus in a state of complete prolapse, or after it has been 
replaced, a Sims' speculum being used. Dr. Thomas describes (1) 
the operation as applied to the anterior wall while the uterus is in 
a state of prolapse. 

' ; The patient having been etherized and placed upon her back, 
a portion of the vagina, about half an inch to one side of the cer- 
vix, is caught up with the tenaculum, and a piece the size of a 
buckshot cut out with scissors. Through this opening a grooved 
director is passed directly across the anterior face of the uterus, 
and between it and the vagina, to a point on the other side, corre- 
sponding to that which marked the commencement of the opera- 
tion. Upon this director the vagina is cut transversely. Entering 
the director now at the middle point of the transverse cut, it is 
gradually insinuated through the loose areolar tissue between the 
bladder and the vagina, until it reaches a point near the meatus, 
when it is withdrawn. This insertion I have found quite easy. 
An instrument of steel (Fig. 91), six inches long, shaped like an 




Fig. 91.— Thomas' Dilating forceps for separating the bladder and vagina. 

ordinary glove-stretcher, with limbs equal in size to a Xo. 9 steel 
sound and three inches long, is then passed down the channel made 
by the director. When the lowest point of this is reached, the 
blades are thrown apart by approximation of the handles and a 
subcutaneous tearing is accomplished, so as to separate the blad- 

1) Op. Cit., p. 354. 



120 A TEXT-BOOK OF GYNECOLOGY. 

der from the vagina over a triangular space, the apex of which is 
at the urethra and the base at the cervix. If the tissue does not 
yield readily, the finger is made to aid the stretcher, and the sep- 
aration is readily accomplished. (The stretcher may be dispensed 
with and the tearing accomplished by a sound.) 

' ' A clamp three inches long, with blades half an inch wide, 




Fig. 92.— Thomas' Vaginal Clamp with teeth for compressing wound in 
vagina. 

and having two rows of teeth, a quarter of an inch in length, 
fixed upon their inner faces, is then applied. 

"This clamp, the limbs of which are united by a hinge, ad- 
mitting a separation of a quarter of an inch at one extremity, is 
united by a screw at the other, which can be graduated as to the 
degree of compression which it accomplishes. The separated 
vagina is then brought together by a suture at the cervix, which 
passes through it at the point where the operation was commenced. 
This being tightened, the free portion of the vagina is folded so as 
to protrude as two flaps, turned face to face. The clamp is then 
adjusted, with the hinge toward the cervix and the screw toward 
the urethra, and tightened by the screw. Then the portion of the 
vagina hanging out of the clamp is cut off near the edge of the 
clamp, interrupted silver sutures are passed so as to secure the lips 
of the wound, and, the clamp being still in place, the uterus is re- 
placed, a procedure involving no difficulty. The vagina is then 
filled with a tampon of cotton wet with solution of alum and car- 
bolic acid. This is applied quite firmly, so as to control any hem- 
orrhage which may occur from the transverse incision near the 
cervix, or from the torn recto-vaginal septum. In twenty-four 
hours the tampon should be removed, in forty-eight the clamp 
should be taken off, and in eight or nine days the sutures with- 
drawn. 

t; Usually both walls require operation, an interval of two or 
three weeks intervening between the procedures. Between the 
operation of the vaginal wall, after restoration of the uterus to its 
place and that where the uterus is prolapsed, there is this differ- 
ence: In the first case, the uterus being in the pelvis at the time 
of operation, the transverse incision would prove difficult of accom- 
plishment, and should not be made. The opening of the vaginal 
wall should be made just above the fourchette, and through this 



EPISIORRHAPHY. 121 

the stretcher introduced. After separation of the vagina from the 
rectum, the clamp is applied and the overlapping vagina cut off." 

The greatest danger is from hemorrhage, but this is controlled 
by means of the clamp. 

Dr. Thomas very justly remarks that "It is never safe to 
promise a good and prominent result from any of the operations of 
elytrorrhaphy. If in a case of enlargement of the cervix, relax- 
ation of the vagina, and complete distension or rupture of the 
perineum, the patient is willing to submit to three operations, 
amputation of the cervix, elytrorrhaphy upon anterior wall, and 
closure of the perineum, cure will often be complete and perma- 
nent. This is a trying ordeal, both mentally and physically; never- 
theless, most women affected by prolapsus in the third degree would 
unhesitatingly accept one of even greater severity with the prospect 
of cure." 

3 . Episiorrhaph y. — This operation consists in freshening the 
edges of the labia majora and uniting them by silver sutures, thus 
partially closing the vulvar orifice and preventing eversion of the 
vaginal walls and hindering the mechanism of descent. Either the 
knife or scissors may be used for the denudation, care being taken 
to avoid all excavation of tissue. The sutures are introduced 
about one-third of an inch apart, sufficiently deep to completely 
encircle the denuded surfaces. They are to be removed on the 
tenth day. 



CHAPTER XIII. 



VAGINAL FISTULA. 



Definition. — A solution of continuity in the vaginal walls, 
by which a communication is established between the vagina and 
adjacent organs and tissues. 

Varieties. — There are several varieties of vaginal fistulse, both 
urinary and fecal, according to the location of the fistulous open- 
ing, but for practical purposes it is only necessary to describe the 
chief form of each, under which heads the other varieties may be 
readily included. I shall, therefore, refer to but two varieties, 
viz., (1) vesico-vaginal fistula, where the communication is with 
the bladder, and (2) recto-vaginal fistula, where the communication 
is with the rectum. The accompanying diagram (Fig. 93) shows 




Fig. 93. — Diagram showing the principal varieties of vaginal fistulse. 1. 
The fundus uteri; 2. The rectum; 3. A utero-vesical fistula; 4. A vesico- 
vaginal fistula; 5. A recto-vaginal fistula; 6. The vagina; 7. A urethro- 
vaginal fistula; 8. The urethra. 



the principal varieties of vaginal fistulse. A fistulous opening 
between the intestines, above the rectum and vagina, is known as 
entero-vaginal fistula, but it is of rare occurrence, and seldom de- 
mands operative interference. 



V2--i 



VES1C0-VAGIXAL FISTULA. 123 

I.—Vesico- Vaginal Fistula. 

Etiology axd Pathology. — A vesicovaginal fistula may be 
situated at am^ point along the vesical tract from the urethra to 
the fundus of the bladder, and may be so small as to almost defy 
detection, or it may involve the entire posterior wall of the blad- 
der. 'When recent they are of larger size than later, since they 
become contracted by the formation of cicatricial tissue. ;, The 
margins of the fistulae are at first irregular, swollen and ulcerated, 
but after a time they become thin and firm, through cicatrization." 

••In cases of fistulas which allow a free flow of urine, the 
bladder becomes permanently contracted and its Avails thickened; 
in large fistulas, the mucous membrane protrudes through the 
opening, and is easily recognized from its deep red color. The 
normal relations of the openings of the uterus to that of the 
urethra and to the cervix uteri render them liable to be involved 
in an extensive fistula, or even in a small one lying to one side of 
the middle line. Sometimes we can recognize their openings on 
the exposed vesical mucous membrane by means of the urine trick- 
ling from the orifices. Should the urine be blood-stained, it can be 
distinguished from blood by its acrid reaction to test paper. The 
urethra, through disuse, becomes contracted; sometimes a com- 
plete atresia is present and seriously complicates treatment, and a 
portion of the canal may even be completely destroyed by pressure. 
The vagina is often contracted by cicatricial tissue, originating 
from injuries received during labor. The margins of the fistula 
are often drawn apart, and sometimes fixed down to the bone by 
these cicatrices; this interferes with their closure. Contraction of 
the vagina below the fistula sometimes makes it impossible to 
ascertain the condition of the upper part, and whether the uterus 
communicates with the fistulous tract." (1) 

Vesicovaginal fistula is almost invariably caused by injuries 
received during parturition. In protracted labor the presenting 
head may so press against the soft parts that their nourishment is 
cut off and gangrene follows, resulting in a loss of substance by 
sloughing, leaving a fistulous communication between the vagina 
and bladder. Schroeder says (2): ;> The long duration of the 
pressure is especially important, since a momentary squeezing of 
the soft parts, even though very severe, is not apt to produce 
mortification, while a pressure which is very long continued does 
not need to be so very great to produce the injurious effects. 

• • A very severe pressure hardly ever takes place before the 
waters have escaped, for until then the force acting directly upon 
the child is very slight. Hence, labors which are very long pro- 

1 1 Hart and Barbour. Op. Cit.. p. 5S6. 
2; Ziemssen. Vol. X. p. 514. 



124 A TEXT-BOOK OF GYNECOLOGY. 

traded after rupture of the bag of waters, the head presenting, 
rank first in importance in the causation of fistulee." 

A fistula may also be produced by the careless or unskillful 
use of forceps or other obstetrical instruments, but it is most likely 
that in many instances where such is supposed to be the cause, the 
real cause, the prolonged and violent pressure above mentioned, 
has been lost sight of. 

Direct injury may produce a fistula, as, for example, falling 
on a pointed object which penetrates the vagina. 

Fistula has also resulted from inflammation and ulceration 
caused by badly-fitting pessaries. 

Carcinoma is a frequent cause of fistula, but such cases being 
incurable they will not be considered here. 

Symptoms. — The involuntary escape of urine through the 
vagina is the chief symptom. According to the size of the fistu- 
lous opening, its location, and the changes in position of the 
patient, do we have variations in the flow of urine, being greater 
under some circumstances than others. At times all the urine 
may escape through the vagina, while at others a portion of it is 
discharged through the normal outlet. In small fistula the urine 
is mostly passed normally, but at the same time a small quantity 
continually trickles from the vagina down the thighs. 

Secondary symptoms often result from the irritation pro- 
duced by the continued passage of urine over the parts. Vaginitis, 
vulvitis, pruritus, excoriations, ulcerations and vesicular erup- 
tions occur, while at the same time the perpetual moisture of the 
genitals and thighs and the urinous odor accompanying it excludes 
the patient from society and renders her life miserable, so that the 
general health becomes impaired, and hysteria, chlorosis and even 
graver disorders become manifest. 

Diagnosis. — Usually the diagnosis is easily established, even 
before an examination, as constant escape of urine rarely occurs 
from other causes. If the fistula be large, it is readily discovered 
by passing a sound into the bladder, white the index finger placed 
in the vagina feels the sound through the opening. Sims' speculum 
will reveal the location and extent of the fistula. If the fistula be 
small, it is better, after introducing a Sims 1 speculum, to inject the 
bladder with milk, or with water colored with permanganate of 
potash or some other substance, and as the bladder distends watch 
the anterior wall for the point at which the fluid escapes. This 
being discovered, the finger and sound will readily establish the 
extent of the opening. 

Prognosis. — As a rule the prognosis is favorable. Small and 
recent fistula? sometimes heal spontaneously during the puerperium. 
Large ones require an operation, which, though not at all formid- 



VESICO- VAGINAL FISTULA. 125 

able in character, requires considerable skill and experience on the 
part of the operator. Sometimes it becomes necessary to repeat 
the operation two or three times before it is successful. Those 
cases in which the margins of the fistula contain considerable cica- 
tricial tissue and are bound down by adhesions are the most diffi- 
cult to cure. 

Treatment. — Recent cases of vesico-vaginal fistula will some- 
times heal spontaneously, but if discovered within a few days after 
parturition, we should attempt to aid nature in her efforts at 
repair. This may be done by introducing a catheter into the 
bladder and leaving it there, that the urine may pass off through 
the natural channel, and syringing the vagina out frequently with 
warm water. It is said that the abdominal decubitus also aids in 
the repair. Tampons are sometimes used, but by stretching the 
anterior vaginal wall they are liable to do more harm than good. 

Very small fistulae arc sometimes closed by cauterization, 
either with nitrate of silver or the red-hot wire, but this method 
cannot be depended upon in fistulse of any size. Failure by this 
method leaves cicatricial margins, and thus renders subsequent 
operative measures more difficult and less successful. 

In all large fistulee, and in most small ones, surgical measures 
are required. The operation for closing a fistula consists in fresh- 
ening the edges of the wound and uniting them by means of silver 
wire sutures. 

It is important that the operation be preceded by proper pre- 
paratory treatment. For several days, or even weeks, beforehand, 
the patient should receive daily vaginal injections of hot water, 
followed each time by a free inunction of the parts about the 
fistula and the outlet of the vagina with vaseline, to protect them, 
as far as possible, from the irritating effects of the urine. 

If the edges of the wound become incrusted with phosphatic 
deposits, Dr. Emmett recommends that these be carefully removed, 
as far as possible, by means of a soft sponge, and the remaining 
raw surface brushed over with a weak solution of nitrate of silver. 
When there are cicatricial bands drawing the margin of the fistula 
apart, or contracting the field of vision, these should be divided 
with a pair of scissors, and a glass vaginal plug introduced and 
kept in place for a week or ten days, or the vagina may be kept dis- 
tended by means of an air-bag. 

For the operation five assistants are required, one to take 
charge of the anesthetic, one to hold the speculum, two to hold 
the edges and retract the labia, and another to hand instruments, 
sponges, etc. It is better to use an anaesthetic to keep the patient 
quiet and allow the operator more freedom in exposing the parts, 
though the actual pain of the operation does not require it. 



126 



A TEXT-BOOK OF GYNECOLOGY. 



The operation is composed of six successive steps, each of 
which should be borne in mind as essential to success: (1) com- 
plete exposure of the fistula; (2) thorough freshening of the edges; 
(3) introduction of the sutures; (4) carefully approximating the 
edges and securing the sutures; (5) introduction of a catheter into 
the bladder; (6) careful removal of the sutures at the proper time. 

1. Exposuke of the Fistula. — The patient having been 
anaesthetized is placed in the lithotomy position, and the legs 
being strongly flexed are held by two assistants, who also hold 
back the labia with retractors, a third assistant retracting the pos- 
terior wall of the vagina as far as possible with a Sims' speculum. 
If the edges of the fistula do not sufficiently protrude, or there is 
a tendency for the mucous membrane of the bladder to prolapse 
through the fistula, it may be necessary to overcome these difficul- 
ties by introducing a catheter or sound into the bladder. Some 
operators prefer the semi-prone position, while Bozeman recom- 
mends the genu-pectoral position, and has invented an apparatus 
(Fig. 94) by which the patient can be secured to the table. I pre- 




Fig. 94. — Bozeman's position for vesieo-vaginal fistulse. 



fer the lithotomy position, but if in any case a better exposure of 
the fistula could be obtained I should not hesitate to adopt either 
of the other positions mentioned. Fig. 94 J represents an improved 
Gynapod devised by Dr. T. G. Comstock, of St. Louis, and which 
has been received with favor by eminent gynecologists. It con- 
sists of a set of adjustable leg-braces that support the limbs of 
the patient comfortably when she is lying in the dorsal position. 
By their use the whole weight of the thighs and legs are lifted 
upward from the pelvis, and, by a simple device, a fixed perineal 
retractor is applied, so that the surgeon can conveniently sit before 



VESICO-VAGINAL FISTULA. 



127 



the patient and operate with the greatest ease to himself and with 
comparatively little inconvenience to the patient, and at the same 
time he can dispense with assistants other than the nurse and the 
one who administers the anaesthetic. This apparatus is especially 




Fig. 94£. 

useful in all minor operations, including those for vesico-vaginal 
fistula, cystocele, rectocele, lacerated cervix, etc. 

2. Freshening the Edges. — The lower border of the 
fistula is seized with a tenaculum (Fisj. 95) or long finely-toothed 



G 



L-G. 



gfs- 



Fig. 95. — Tenacula. 



forceps, and a strip of vaginal mucous membrane, one-fourth to 
one-sixth of an inch wide, is carefully removed about the edge of 
the orifice, leaving the vesical mucous membrane intact, but paring 
close up to it (Fig. 96). This freshening should extend well 
beyond the angles of the wound, in order to provide against the 
possibility of a small fistula remaining at these points. When the 
septum is very thin it may be difficult to obtain a sufficient extent 
of raw surface, and it may be necessary very carefully to split the 



128 



A TEXT-BOOK OF GYNECOLOGY. 



layers between the vagina and bladder, making the non-mucous 
surface of each to play a part in the new cicatrix. 

For this purpose we may use either long-handled curved scis- 




Fig. 96.— Method of paring the edges of a fistula (Simon). 




Fig. 97.— Long-handled Curved Scissors 



sors (Fig. 97), Emmett's double-curved scissors (Fig. 98), or long- 
handled small bistouries, straight, or set at an angle (Fig. 99). 
I prefer Emmett's curved scissors, but if for any reason a knife 



VESICO-VAGINAL FISTULA. 



129 



can be more advantageously used, I would recommend Sims' rota- 
ry knife (Fig. 100), which can be placed and held firmly at any 
desired angle. The reason for avoiding the vesical mucous mem- 




Fig. 98.— Emmett's Curved Scissors. 




Emmett's Double Curved Scissors. 



brane is on account of the danger of after-hemorrhage into the 
bladder. If it has been cut and shows signs of bleeding freely, 
the bleeding edge should be seized with a pair of artery forceps, 




Fig. 99.— Knives for paring a fistula. 

or, if that fails, a catgut ligature may be passed through the vag- 
inal wall into the bladder and out again at a very short distance 
from the raw edge, so as to encircle the bleeding vessel. Emmett 
says such ligatures must never be placed more than half an inch 



130 



A TEXT-BOOK OF GYNECOLOGY. 



from the middle line, to avoid involving the ureters. Usually any 
hemorrhage occurring during the operation may be checked by the 
hot douche. 

3. Introduction of the Sutures. — The freshened edges 
are now to be brought in accurate contact by means of silver wire 



;««illi« 



Fig. 100. — Sims' Rotary Knife. 

sutures. For the introduction of the sutures I prefer laterally- 
curved needles on fixed handles (Fig. 101), but an ordinary curved 
needle may be used, or hollow needles (Fig. 102). Emm ett pre- 
fers to use short, round needles, from one-half to three-quarters 



If 9 

Fig. 101.— Laterally Curved Needles on Fixed Handles. 

of an inch in length, slightly curved at the point, which are intro- 
duced by means of a needle-holder, carrying with them a loop of 
silk. This loop is used to draw back through both sides of the 




Fig. 102.— Hollow or Tubular Needles. 

fistula the end of a silver wire hooked around it. The space be- 
tween the stitches should be about one-sixth of an inch. To pre- 




FiG. 103. — Bozeman's Fork. 

vent the sutures from cutting the vaginal mucous membrane as 
they are drawn through, the forks may be used (Fig. 103), and if 



VESICO- VA GINAL FIS TULA. 



131 



the needle does not pass readily counter-pressure may be made 
with the blunt hook (Figs. 104, 105). 

4. Approximation of Edges and Securing of Sutures. — 
All the sutures having been passed and the edges of the wound 



Fig. 104.— Blunt Hook. 



carefully approximated, the sutures arc twisted by the aid of Sims' 
wire adjuster (Figs. 106, 107) and Emmett's twisting forceps 
(Figs. 108, 109). The ends of the sutures are then cut off 
about half an inch from the wound and bent at a right angle. 
The bladder should then be carefully syringed out with warm 
water to remove any blood that may have accumulated. Emmett 
recommends that the bladder be washed out before the sutures are 




Fig. 10H. — Passing the needle. (Wieland and Dubrisay.) 

twisted, the water and coagula, if any, being allowed to escape at 
the wound. 

' 5. Introduction of a Catheter. — This is important in 
order that the bladder may be continually drained through the 
proper channel while the wound is healing. Sims 1 sigmoid cath- 
eter (Fig. 110) is by far the best instrument to use. It is best to 
have two catheters, so that several times a day they can be changed 
and carefully cleansed. A small china dish with a broad bottom 
may be used as a receptacle for the urine. 

The catheter should be allowed to remain for a few days after 
the sutures have been removed. 

6. Kemoval of the Sutures. — This should be done about 
the tenth day. The twisted end of each suture is seized by a pair 
of forceps and cautiously drawn clown until the edge of the loop 



132 



A TEXT-BOOK OF GYNECOLOGY. 



is visible, which is then snipped off with a pair of scissors and a 
little further traction with the forceps withdraws the suture. 

When the vesico-vaginal fistula is located close to the cervix, 
or the tear implicates the cervix, as it sometimes does, the anterior 




Fig. 106.— Twisting the 
sutures. 



Fig. 



107.— Sims' Wire 
Adjuster. 



Fig. 108.— Emmett's 
Twisting Forceps. 



lip may be used to close the rent, its surface, as well as the mar- 
gins of the tear, being freshened, and the two united by sutures. 
(Fig. 111). 

In case the fistula is vesico-uterine, the cervix is divided up to 
the fistula, the edges of the fistula pared, and otherwise treated as 
a vesico-vaginal fistula. If the fistula is located in the urethra, it 
is more accessible to treatment, but the tissues are very thin. For 
this reason Emmctt recommends freshening a portion of the vaginal 
tissue also, the fistula being kept well in view during the opera- 
tion by retaining a full sized gum-catheter in the urethra. 

Closure of the Vagina. 

In those cases in which there is such an extensive destruction 
of tissue that the operation above described is impracticable, or in 



VESICO-VAGINAL FISTULA. 133 

those in which the operation has been performed several times 
without success, another method of treatment is necessary, and in 
cases of uterine fistula, which are inaccessible to treatment, the 
only means of relief consists in a transverse closure of the vagina 
below the fistulous opening. By this means the vagina and blacl- 




Fig. 109. — The fistula with edge pared and the sutures placed. 

der become a common receptacle for urine and menstrual blood, 
both of which are discharged through the urethra. 

This operation was first performed by Simon, who termed it 
"kolpokleisis," which signifies cross-obliteration. It consists in a 




Fig. 110. — Sims' Sigmoid Catheter. 

freshening of the anterior and posterior vaginal walls at corre- 
sponding points, as high as possible, so as to be below the fistula, 
and uniting these surfaces by silver wire sutures (Fig. 112). 

Of course it should be remembered that this method of treat- 



134 



A TEXT-BOOK OF GYNECOLOGY. 



merit destroys all possibility of conception, though usually it does 
not entirely preclude the sexual act. In bad cases of fistula these 
facts are scarcely to be considered, though the patient should be 
thoroughly advised on the subject before the operation is per- 
formed. 

2. Recto-Vaginal Fistula. 

Etiology. — The causes are very similar to those of vesico- 
vaginal fistula, injury during labor being the most frequent. In 
such instances, however, prolonged pressure is rarely the cause, 
the origin of a recto-vaginal fistula being most often in lacerations 




Fig. 111. — Sutures passed through anterior lip of cervix so as to close in 
transversely a fistula of the anterior fornix (H. and K). 

of the posterior vaginal wall. Frequently a perineal rupture in- 
volving the recto-vaginal septum subsequently heals in part pri- 
marily, or from operative interference, leaving a portion or all of 
the recto-vaginal septum open. 

Rectal fistula may also, in rare instances, result from the use 
of instruments during delivery, from badly-fitting pessaries, and 
from ulcerations and abscesses in the posterior vaginal wall. A 
retention of hardened feces from stricture of the rectum, or from 
other causes, may result in ulceration which extends through the 
vaginal wall. 

Symptoms. — The chief symptom is the escape of offensive gas 
and fecal matter through the vagina, the amount discharged de- 



RECTO-VAGINAL FISTULA, 



135 



pending upon the size and location of the fistula. On account of 
this discharge the patient suffers great inconvenience and distress, 
both mental and physical, which tends to destroy the health and 
render the patient's life miserable. 

Diagnosis. - — If the fistula is of any size it may usually be 
detected with the finger, or by ocular inspection, the anterior 




Fig 



112.— Simon's Operation for Kolpokleisis. The patient is in the 
lithotomy posture; the sound has been passed through the urethra and 
is seen in the upper portion of the vagina; the perineum is drawn back 
with the speculum and the labia majora with spatula?. A band-like 
piece of tissue has been removed, from both the vaginal walls above the 
ostium: the raw surface is left unshaded in the figure. The vaginal 
mucous membrane is held tense by four pairs of forceps outside the 
raw surface, the shaded area within the latter is the upper third of the 
vagina. An end of the last suture has been passed through one raw 
surface, the second end is being carried through the other raw surface 
■ (H. and K.) 



vaginal wall 



being raised by a Sims' speculum, and the lateral 
walls retracted. If the fistula is too small to be discovered in this 
manner, a colored fluid may be injected into the rectum, and the 



136 A TEXT-BOOK OF GYNECOLOGY. 

posterior vaginal wall carefully watched in order to detect the 
point at which the fluid escapes into the vagina. 

Pkognosis. — Recent recto-vaginal fistulse are more apt to heal 
spontaneously than a vesico-vaginal fistula, as they are not subject 
to the irritating influences of a urinary discharge. In a majority 
of instances, however, an operation is required, the prognosis as to 
cure being about the same as in the vesico-vaginal variety. 

Treatment. — This is practically the same as in the vesico- 
vaginal fistula. The rectum having been thoroughly emptied by 
an enema, the patient is placed in the lithotomy position and a 
Sims' speculum introduced anteriorly, the lateral walls being sep- 
arated by retractors, a large bougie is then introduced into the 
rectum, by which the fistula is kept prominent. The edges are 
freshened and the sutures inserted in the same manner as in vesico- 
vaginal fistula. Simon recommends, in the more difficult cases, to 
unite the edges by sutures introduced within the rectum. In order 
to insert these rectal sutures it is necessary to previously stretch 
and paralyze the rectum, and then to introduce a Sims' speculum 
within it. In such cases a firm catgut suture should be used 
instead of silver wire, in order to avoid the pain and annoyance of 
their removal. 

Vaginal injections of warm calendula water should be used 
daily, and the bowels kept in a lax condition by the use of proper 
diet, and even by daily enemas, if necessary. It is a mistake to 
lock up the bowels by the use of opiates, as the hardened feces 
which must pass when the bowels are reopened may destroy the 
good results of the operation. 



CHAPTER XIV. 

DISEASES OF THE UTERUS. 
Malformations. Congenital Atrophy. Hypertrophy of the Cervix. 

Malformations . 

By this term is meant those conditions of arrested develop- 
ment and arrested growth of the uterus which, while they are, as 
a rule, not amenable to treatment, are nevertheless of great im- 
portance to the student of gynecology. The chief varieties of 
these malformations will be briefly mentioned, the student being 
referred to more exhaustive treatises for their full consideration. 

To understand these conditions the student must remember 
that the entire genital tract in the female is developed out of Mid- 
ler's ducts, which originally consist of two parallel tubes which 
gradually coalesce during the first weeks of embryonic life to form 
the vagina and uterus, the upper portion remaining separate and 
constituting the Fallopian tubes. If one or both of these ducts be 
absent, or fail to coalesce, or become retarded in development in 
any manner, the result is a corresponding defect or arrest in devel- 
opment of the genital canal. 

According to Arnold the period of development of the uterus 
is twenty weeks, while the period of growth extends to the twen- 
tieth year, therefore all cases of malformation which originate 
after the twentieth Aveek of embryonic life are instances of arrest 
in growth, rather than in development. 

Malformations of the uterus may, therefore, be separated into 
two divisions : (1) Those which are the result of an arrest in 
development, and (2) those which are the result of an arrest in 
growth. In the first group arc. 

1. Absence of the uterus ; 

2. Rudimentary uterus ; 

3. Uterus duplex separatus ; 

4. Uterus unicornis ; 

5. Uterus bicornis ; 

6. Uterus septus ; 

7. Uterus subscptus. 
In the second group are, 

1." Uterus foetalis; 

2. Uterus infantilis ; 

3. Congenital atrophy. 

In addition to these varieties we may also have an excessive 

137 



138 A TEXT-BOOK OF GYNECOLOGY. 

development, or an abnormal size of the uterus, which is congen- 
ital in its nature. Such are the cases of precocious development 
which are recorded, and which are usually also accompanied by a 
premature development of the breasts, external genitals, and hair, 
and by precocious menstruation. 

1. Absence of the Uterus. — An entire absence of the 
uterus is extremely rare. It is probable that in most cases so 
reported there are really traces of a rudimentary structure which 
was originally destined to become a uterus. In such cases there is 
either an absence or a rudimentary development of the vagina, 
Fallopian tubes and ovaries. 

2. Rudimentary Uterus. — In some instances only a glob- 
ular, solid, fibrous mass about the size of a hazelnut is found ; 
sometimes there is to be found only a band of muscular fibre and 
connective tissue on the posterior wall of the bladder ; other cases 
show a solid mass shaped like the body of the uterus, and possess- 
ing rudimentary horns and round ligaments ; in others there is a 
hollow membranous body shaped like a normal uterus. The most 
frequent form of rudimentary uterus, however, is that known as 
the uterus bipartitus, where we find lying between the bladder and 
rectum a body which resembles the normal uterus in shape, and 
which is composed of connective tissue interspersed with muscular 
fibres, and possessing rudimentary horns, which may be either 
solid or hollow. There may be more or less of a neck, which is 
inserted into the roof of the vagina. In such cases the ovaries 
and external genitals are usually somewhat rudimentary, but they 
may be well developed, and normal menstruation and ovulation 
may occur. 

3. Uterus Duplex Separatus. — Here Midler's ducts re- 
main separate, and do not coalesce to form the uterus, which 
results in two separate uteri, each one representing one-half of the 
normal uterus. The condition is very rare, and is usually found 
in foetal monstrosities. 

4. Uterus Unicornis. — In this type the uterus has but one 
horn, though the other horn may exist in a rudimentary state. 
The body of the organ is disproportionately long, and curves to 
one side, ending in a point from which start a Fallopian tube, an 
ovarian ligament and a round ligament. The intra-vaginal por- 
tion is generally small, and the vagina narrow. The rudimentary 
horn of the other side may be either solid or hollow, and lie close 
to the uterus, or greatly diverge from it. It has a Fallopian tube 
and ovary, which are sometimes fully developed, it being difficult 
to establish the point at which the rudimentary uterus ends and 
the tube begins. Pregnancy may occur in a one-horned uterus, 
and terminate favorably. If, however, the foetus becomes estab- 



UTERINE MALFORMA TIOXS. 



139 



lished in the rudimentary horn it will cause rupture, and there 
will follow the usual symptoms following such an accident in tubal 
pregnancy. 

5. Uterus Bicornis. — This is the double uterus, both horns 
becoming fully developed, but remaining separate, each side repre- 
senting a separate cavity, which may open by one orifice into one 
vagina, or, the separation may extend to the vulva, giving two 
uterine orifices and two distinct vaginae. The two bodies may lie 
contiguous to each other, the double organ showing only a slight 
depression at the fundus, or they may widely diverge at the point 
of union, which may be at the cervix, or higher up. 

6. Utekus Septus. — In this variety of malformation the 
external appearance of the uterus is normal, but it is divided in- 




Fig. 113. — Uterus with double cavity, and slight deviation of form. 

temally into two halves by a longitudinal septum which extends 
to the external os; a septum may also divide the vagina into two 
parts. 

7. Uterus Subseptus. — This condition is the same as in 
uterus septus, except that the septum is incomplete, reaching only 
from the external to the internal os, or but a short distance into 
the cavity. Menstruation and ovulation occur normally in a 
double uterus, and pregnancy may take place, a foetus- fully de- 
veloping in either one or both halves. 

The malformations which are the result of an arrested growth 
are : 



140 



A TEXT-BOOK OF GYNECOLOGY. 



1. Uterus Fcetalis. — Here the uterus is normally formed, 
but during the latter half of gestation its growth is arrested. 

2. Uterus Infantalis. — Here the arrest of growth takes 
place after birth, but since the uterus remains very slightly 
changed from birth until puberty, there is practically no difference 
between the uterus fcetalis and the uterus infantalis. The uterus 
is, of course, smaller than normal, but the chief peculiarity lies in 
the disproportionate length of the cervix as compared with that of 
the body, being two or three times as long. The walls are thin 




Fig. 114. — Uterus septus bilocularis; double uterus, with single vagina 
seen from the front; left walls more developed in consequence of preg 
nancv. (Cruveilhier.) 



seen „ 

nancy. (Cruveilhier.) 

and the cavity small. Menstruation usually does not occur, and 
conception is impossible, though copulation may take place with 
entire satisfaction. 

3. Congenital Atrophy. — This differs from uterus in- 
fantalis in that the shape of the uterus is normal, the cervix and 
body being proportionate, but the whole organ is small and its 
walls thin and flabby. This may occur in girls who are perfectly 
healthy and otherwise well developed, but is usually present in 
chlorotic or scrofulous subjects, and, not infrequently, it is asso- 
ciated with hysteria and epilepsy. There is usually amenorrhea, 



UTERINE MALFORMATIONS. 



141 



bat sometimes scanty menstruation, associated with pain in the 
back and abdomen, and various nervous and mental phenomena. 

Diagnosis. — The diagnosis of uterine malformations during 
life is often impossible. The symptoms are usually only those of 
impairment of function, such as may arise from other causes. The 




a 

Fig. 115. — Double uterus and vagina from a girl aged nineteen (Ersenniann). 
a, double vaginal orifice with double hymen; b, meatus urethras; c, 
clitoris: d\ urethra: e, e, the double vagina; f, f, uterine orifices; g, g, 
cervical portions; h, h, bodies and cornua; i, i, ovaries; k, k, Fallopian 
tubes; Z, I, round ligaments; m, m, broad ligaments. (Courty.) 

appearance of the patient and the development of the breasts and 
external genitals may not indicate any departure from normal. 
Sometimes the use of the sound, with subjoined careful bimanual 
or rectal examination, will establish the deformity, or the small- 
ness of the uterus, whichever those may be. In all instances the 
use of the sound is attended with more or less danger. The walls 



142 A TEXT-BOOK OF GYNECOLOGY. 

of the uterus are in some malformations as thin as paper, and 
slight pressure with the sound may penetrate them and cause fatal 
inflammation. 

Treatment. — There is but little that can be done for these 
malformations in the way of treatment. The uterus fcetalis and 
infantalis, and the congenitally atrophied uterus, may often be im- 
proved by the careful use of electricity, the positive pole being 
applied over the mons veneris, and the negative pole attached to a 
uterine sound being inserted into the uterus. This treatment 
should be repeated at least twice a week, and probably for several 
months. At the same time the patient should be given a system- 
atic course of bathing, diet and exercise, having in view the devel- 
opment and strengthening of the entire physical system. The sub- 
jective symptoms should be combated with the indicated remedy. 

When malformations give rise to the retention of menstrual 
blood or the products of conception, surgical interference may be 
required, which will be elsewhere considered. 

Atrophy of the Uterus ; Superinvolution. — This term 
is used to signify not a congenital defect, but a condition that has 
been acquired after puberty. It may involve the whole uterus, or 
simply the cervix or vaginal portion. 

Normal atrophy of the uterus occurs after the climacteric, 
and should atrophy occur at any time after puberty and before 
the climacteric, i. e., during the period of ovarian activity, it is 
an abnormal condition, and requires treatment. 

Etiology. — Atrophy of the uterus may be caused by the 
pressure of an ovarian or fibroid tumor, or follow a long-lasting 
chronic catarrh ; it may also occur as a consequence of certain 
blood states, such as phthisis, scrofula and chlorosis, though in 
chlorosis it is probable that the atrophy is generally congenital, 
and is not secondary to the blood states. Atrophy also results 
from a superinvolution after childbirth, there being in such cases 
a failure in the appearance of the menstrual flow after childbirth 
and lactation. As has been noted, atrophy of the uterus occurs 
as a normal condition after the climacteric, and in estimating the 
causes of this condition it should be remembered that the meno- 
pause may occur as early as the thirtieth year, of which I have 
seen one case, and normal atrophy follow. 

Pathology. — In cases of superinvolution the uterus is 
reduced in size to nearly one-half its normal depth. The walls 
arc generally thin, though sometimes they are thick. But it must 
be borne in mind that they are generally soft and pulpy, so that 
they may be easily perforated by the sound if force is used. The 
os is patulous, or may be hard and contracted. In atrophy from 
other causes the uterus is usually very thin and flabby, the exter- 



ATROPHY OF THE UTERUS. 143 

nal os is only a small opening bounded by thin folds, and located 
almost on the surface of the vaginal roof, the infra-vaginal portion 
of the cervix having disappeared. 

Symptoms. — The chief symptom is a premature cessation of 
menstruation, and following this various symptoms of nervous 
disturbance, such as pain in the back, debility, mental depression 
and hysteria. 

Diagnosis. — Examination shows a patulous os, but with a 
small opening, and the sound shows a decrease in depth. The 
sound must, moreover, be used with great caution, for but little 
force is required to perforate the uterine walls. I do not think 
much knowledge can be gained from either a bi-manual or rectal 
examination, though it is possible that in some instances the size 
of the atrophied uterus may be clearly established by one or the 
other of these methods. The diagnosis from congenital malforma- 
tions, and from normal atrophy following a normal menopause, 
can only be established from the history and symptoms of the 
case. 

Prognosis. — As a rule the prognosis is unfavorable, though 
in some instances the uterus has by proper attention been returned 
to its normal size and function, so that the treatment of such cases 
should not be neglected. 

Treatment. — Should there be present a constitutional taint, 
such as tuberculosis, scrofulosis or chlorosis, this must be com- 
bated with the appropriate remedies, the most important of which 
are mentioned in the chapter on Chlorosis. Should such a taint 
not be apparent, there may be symptoms present indicating an 
entirely different class of remedies, such as Hclonias, Lilium, Cimi- 
cifuga. etc. 

Ordinarily the chief dependence is to be placed upon methods 
that will cause a stimulation of the uterus. This may be accom- 
plished either by the carefully repeated use of the sound, by the 
introduction of the intra-uterine stem pessary, or by the use of 
electricity. In applying electricity the negative pole should be 
attached to a uterine electrode and applied directly to the os or 
within the cervix, while the positive pole is placed immediately 
above the mons veneris or over the lower lumbar vertebra?. 

Hypertrophy of the Cervix. — This does not include that 
condition of the hypertrophy of the whole uterus known as sub- 
involution, which will be considered under chronic metritis. Hy- 
pertrophy of the cervix may involve either the infra-vaginal 
portion of the cervix or the supra-vaginal portion. The former 
is a primary disease, while the latter is secondary to vaginal or 
uterine prolapsus. 

Hypertrophy of the Infra-Vaginal Portion. — This is. 



U4 A TEXT-BOOK OF GYNECOLOGY. 

more strictly speaking, an elongation of the cervix, for an increase 
in length is the only departure from normal, the cervix being but 
a trifle, if any, thicker, and the mucous membrane only becoming 
sufficiently hypertrophied to cover the elongated portion. The 
condition is entirely non-inflammatory, and is a true hypertrophy, 
differing entirely from those forms of enlargement of the cervix 
which result from chronic inflammation. The causes have not, as 
yet, been ascertained, but it is probable that the condition is often 
congenital. 

Symptoms. — These are usually similar to those which result 
from prolapsus of the whole uterus — backache, bearing-down 
pains, difficult walking, leucorrhea, and, if the elongated cervix 
protrude externally, there is excoriation and frequently ulceration. 

Diagnosis. — There is danger that the inexperienced may con- 
found this condition with prolapsus of the uterus, but the finger 
passed into the vagina may be made to sweep around the elongated 
cervix without pushing up the roof of the vagina, -while bi-manual 
examination reveals the fundus in normal size and position, and 
the sound shows a considerably increased depth. 

Treatment. — This consists in the amputation of the cervix, 
which, however, should not be performed except in cases where 
there can be no question of its necessity. Dr. Emmett says, he 
is " satisfied from experience that the removal of the cervix is 
never called for except in some forms of malignant disease." And 
while it is undoubtedly true, "that this operation, as at present 
applied, is to a great extent a malpractice," yet, there are cases 
where it is imperatively demanded if we have any regard for the 
health and comfort of the patient. Amputation is usually per- 
formed either with the knife or with the galvano-caustic wire. 
The ecraseur is also sometimes used, but as this is not a desirable 
method it will not be here considered. The knife makes the neat- 
est and most satisfactory operation. With it the removal can be 
modified as circumstances may demand, the cut surfaces can be 
accurately approximated, and union by first intention secured. 
Hemorrhage constitutes the greatest objection to the knife, but 
this has no especial weight, considering the means w T e have at 
hand for its control, and secondary hemorrhage is much less apt 
to occur than it is when the operation is performed by the other 
methods named. There arc many operators, however, who prefer 
to make the amputation with the galvano-caustic wire. While 
there is less danger of primary hemorrhage, yet the removal is not 
so accurately done, and smoke so obstructs the operator's vision 
that he cannot tell what he is doing. Besides, cautery instru- 
ments are expensive, and frequently refuse "to go" just when 



INFRA-VAGINAL HYPERTROPHY. 145 

most needed. Nevertheless this method is recommended by Barnes, 
Thomas and other eminent gynecologists. 

Removal by Knife. — This may be done by several methods. 
The simplest plan is to draw down the cervix and slip over it a stout 
india-rubber ring. Then, after having decided just how much to 
remove, make the amputation by a single sweep of a sharp . bis- 
toury. The rubber ring should then be slowly removed by cut- 
ting it with a pair of scissors. If considerable hemorrhage then 
occurs, styptics may be used, or a firm tampon applied. 

According to Hart and Barbour (1) the best method of per- 
forming the amputation is to split the cervix by a transverse inci- 
sion into an anterior and posterior lip; then amputate each lip 
separately, making the line of amputation wedge-shaped; finally 
bring together the projecting flaps of vaginal and cervical mucous 
membrane with wire sutures. 

Several other methods, much more complicated, have been 
highly recommended, but I do not see that they possess any espe- 
cial advantage, and will only mention them, referring the student 
to more extensive treatises for their description. 

The first method is that of Marion Sims, in which a circular 
amputation is made, and then the stump is covered with mucous 
membrane. The next is that of Hegar, who also makes a circular 
amputation, and then stitches the vaginal mucous membrane to 
the cervical mucous membrane. 

Another, and probably a better form of amputation, is that 
introduced by Marckwald, and modified by A. R. Simpson. This 
is a flap operation. Three wire sutures are first passed through 
the cervix at the proper distance. The cervix is then split, and 
the sutures hooked down and each loop cut, thus leaving three 
sutures upon each side. Each flap is then cut away to within 
an eighth of an inch of the sutures, and the latter are twisted, thus 
bringing together the Anginal and cervical mucous membrane on 
each lip. 

Removal by the Galvano-Cautery Wire. — The patient 
is anaesthetized, and after being placed in the semi-prone position 
Sims' speculum is introduced, which had better be made of 
vulcanite than of metal, that it may not be liable to interfere 
with the electric current, should it happen to come into contact 
with the wire. The wire is now slipped over the cervix and tight- 
ened, so that the cervix may be slightly constricted, when con- 
nection is made with the battery, and the wire being slowly 
tightened the cervix is removed, care being taken that the wire 
docs not slip downward and denude the cervix rather than am- 
putate it. 

1) Mart and Barbour, Manual of Gynecology, p. ;>o7. 



146 



A TEXT-BOOK OF GYNECOLOGY. 



The parts are then pushed back, the patient kept quiet for 
about a week, and the vagina daily irrigated with a weak solution 
of carbolic acid. Hart and Barbour recommend packing the vagina 
with carbolized lint or wadding, and renewing the same for a week 
on account of the danger of secondary hemorrhage. 

Hypertrophy of the Supra-Vaginal Portion. — We shall 
not here consider that form of hypertrophy of the cervix which 
results from and is associated with prolapsus, and in connection 
with which it should be considered. 

Etiology. — It is held by some authors that this form of 
hypertrophy is often a primary lesion and that the causes are un- 




Fig. 116.— Diagram of Amputation of Cervix. To the right is seen the 
cervix with the ring constricting it, a suture, MN in position, the cervix 
split and the line of amputation marked 1 to 6; a.f. anterior and p.f. 
posterior fornix. To the left is seen the cervix in cross-section; two 
threads are passed and the needle carried through but not yet threaded 
with the wire iv 

known; and yet, even if this be true, there is little doubt that 
it is most often due to a prolapsus of the vaginal walls. Such 
cases were once supposed to result from prolapsus uteri, but it has 
since been ascertained that the fundus uteri remains in its normal 
position, but the prolapsing vaginal walls, having exerted traction 
upon the cervix, have by this constant irritation caused an increase 
in growth, which is not simply an elongation and attenuation of 
the normal cervical tissues. 



SUPRA-VAGINAL HYPERTROPHY. 147 

Symptoms. — The symptoms resemble those of prolapsus 
uteri, for which the condition is often mistaken. Pain in the back 
and hips, bearing down, difficult locomotion and leucorrhea are 
nearly always present. The menstruation may be regular, but is 
usually very profuse. Cystocele, with its attendant evils, is pres- 
ent unless the hypertrophied cervix is large enough to fill the 
outlet and thus prevent it. 

Diagnosis. — The condition is most often confounded with 
prolapsus uteri, but it is easy enough to discover that while the 
os presents at the -vulva, the fundus is in its normal position, and 
at the same time the sound shows a considerably increased depth. 
The prolapsus of the vagina, in the shape of folds, and its attach- 
ment to the cervix at its proper place of union, includes the condi- 
tion of infra-vaginal hypertrophy. 

Treatment. — The treatment is amputation with the knife, 
the only difference between the operation here and that for infra- 
vaginal hypertrophy being that, on account of the close relation of 
the bladder and peritoneum to the vaginal wall, it is necessary to 
amputate a much smaller portion of the cervix. Hegar recom- 
mended a funnel-shaped incision, terminating in the cervical canal 
at a point higher up than the point of incision. As it is difficult 
to excise enough of the cervix to permanently relieve the patient's 
discomfort, Schroeder recommends pushing up the elongated 
uterus and holding it by a hard rubber ring pessary, and Huguier 
recommends a T bandage in mild cases. 



CHAPTER XV. 



ATRESIA OF THE CERVIX. STENOSIS OF THE CERVIX. 

Atresia of the Cervix. 

Definition. — An occlusion of the cervical canal. 

This condition is occasionally congenital, a tissue covering 
and closing the external os; it is, therefore, sometimes considered 
in text-books as a congenital malformation, but atresia so seldom 
occurs, unless it is acquired, that the congenital form will not be 
here considered. 

Etiology. — Atresia very frequently takes place after the 
menopause, but when occurring at that time it is considered to be 
a physiological condition. Atresia of the cervix is most often 
caused by the application of caustic medicines, and also frequently 
follows amputation of the cervix. It may also be caused by the 
presence of tumors in the cervix, and may result from flexion or 
from catarrh of the cervix. 

Pathology. — The changes which take place as a result of the 
occlusion are chiefly those which follow from the accumulation of 
discharges whose exit is obstructed. According to Schrceder (1): 
"If the external os is obliterated, the whole uterus becomes dis- 
tended from the start. The organ may attain a very great size; 
its walls are generally hypertrophic; occasionally, however, they 
are as thin as paper. The cervix then disappears completely, and 
body and cervix unite in one large cavity. If the internal os is 
closed the cervix remains unchanged, and only the cavity of the 
body undergoes a spherical dilatation. 11 

Ordinarily the distended cavity contains inspissated menstrual 
blood, when the condition is known as hcematometra. If the tubes 
are also distended with blood, we have hamiato-salpinx, which is 
elsewhere considered. Occasionally, menstruation having ceased, 
the uterus secretes a watery mucus, which causes the distension 
known as hydrometra. If the retained fluids become purulent, 
it is jpyometra / or, if they decompose and give rise to gases, the 
condition is known as physometra. 

Symptoms. — These are such as naturally result from the 
retained accumulations, and are quite the same as those of obstruc- 
tive dysmenorrhea, elsewhere considered, partaking of the nature 
of a uterine colic of more or less severity at each menstrual period, 

1) Ziemssen. Vol. X. p. 48. 14S 



STENOSIS OF THE CERVIX. 149 

but no blood escaping. After a time the distress is rarely entirely 
absent, but is greatly aggravated at the menstrual nisus. Sooner 
or later the uterus will become distended, as before mentioned, 
giving rise to a smooth globular tumor; after this has occurred 
the uterine contractions are less painful, and the pain less dis- 
tressing, but the patient is in immediate danger of death from rup- 
ture of the uterus or of the Fallopian tubes, which also become 
distended; or, the blood may escape at the distal end of the tubes 
and cause pelvic hematocele, with its usual consequences. 

Diagnosis. — The absence of a flow at the menstrual period, 
notwithstanding the severe labor-like pains, the gradual formation 
of the smooth, tense, spherical tumor, without the history of preg- 
nancy or of a fibroid tumor or ovarian cyst, and the failure to 
permeate the cervix with a sound, will usually be sufficient evi- 
dence as to the nature of the case. 

Prognosis. — Unless relieved by surgical measures the condi- 
tion is serious. Often the operation, if long delayed, is followed 
by sudden spasmodic contractions and consequent rupture of the 
uterus or Fallopian tubes; at other times the admission of air into 
the cavity by operation induces fatal septicaemia. If these dangers 
are avoided the operation is usually successful and the patient 
entirely recovers her health. 

Treatment.— This consists in an operation for the removal 
of the retained fluids, which should be through the normal medium 
of the cervix, if possible; but instances may arise where it will be- 
come necessary to puncture the tumor from the rectum, or some 
other point than the cervix. 

A long curved trocar and cannula are used for the purpose. 
If the os externum can be located, that should be made the point 
of puncture, but if not, the trocar should be introduced into the 
posterior part of the cervix and carefully pushed upward, follow- 
ing closely the direction of the cervix, until the uterine cavity is 
entered. The opening must afterward be maintained by leaving 
a silver tube in situ, or by the frequent introduction of a good- 
sized bougie. If symptoms of a septic nature, such as rigors and 
high temperature, become manifest, a double-channel catheter may 
be introduced and the cavity frequently irrigated with tepid car- 
bolized water, but otherwise intra-uterine injections should be 
avoided. 

Stenosis of the Cervix. 

Definition. — Stenosis is a contraction of the cervical canal. 
Hart and Barbour define it to be "a concentric contraction of its 
lumen.'' By some authors it is referred to as a partial atresia or 
an incomplete occlusion of the cervical canal. The condition is 
seldom described in text-books, and is referred to only as one of 



150 A TEXT-BOOK OF GYNECOLOGY. 

the causes of obstructive dysmenorrhea. It is, however, as Hart 
and Barbour remark, ' c a precise pathological condition which 
requires a definite line of treatment.' 1 

Pathology. — The external os is usually the seat of the con- 
traction. It may occur in the cervical canal, and probably occa- 
sionally at the internal os, though this is a disputed point. The 
os may be directly adherent, or may be partially closed by 
adhesions of either fibrous or connective tissue. The os is very 
small, hardly as large as a pin-head, which usually lies in the 
center of a slight depression. If the stenosis is congenital, the 
cervix has a conical shape and is of very firm consistence. Some- 
times, with stenosis at the external os, there is also a spasmodic 
contraction of the internal os, or a flexion of the uterus, causing 
obstruction at that point, in which case the cervical canal may 
become dilated, forming a spindle-shaped cavity. 

Etiology. — Stenosis may be caused by the use of caustics, 
or by injuries received from instruments, or from blows or falls. 
It may follow amputation of the cervix, or result from injuries 
during childbirth, or puerperal inflammations, or be caused by 
chronic uterine catarrh or adhesive inflammation of the cervical 
mucous lining. 

Symptoms. — The chief symptom of stenosis is dysmenorrhea, 
the severity of which may vary from a slight uterine colic to one 
of great intensity, the paroxysms of pain being extremely violent. 
The difference in severity depends not only upon the extent of the 
stenosis, but also upon the quantity of the menstrual flow and the 
rapidity with which it is poured out. Sometimes mucus accumu- 
lates in the constricted canal, causing for a time complete occlu- 
sion, which will produce more or less dilatation of the uterine 
cavity, similar to that caused by atresia, but which, as a rule, is 
sooner or later relieved by the violent uterine contractions, which 
finally succeed in removing the obstruction and evacuating the 
uterine contents. Pelvic peritonitis frequently follows as a result 
of the continued uterine irritation, and then its symptoms compli- 
cate those which result directly from the stenosis. 

Sterility is sometimes a consequence of stenosis, and is 
regarded as a symptom, though, of course, it may occur from 
many other causes. 

Diagnosis — When physical examination reveals the conical 
cervix and the pin-hole os, there can be no difficulty in establishing 
the diagnosis. But in acquired stenosis these conditions are not 
so prominent, and a probe or sound must be used; and especially 
is this the case if the scat of stenosis is distant from the external 
os. Stenosis, however, docs not always exist where there is diffi- 



STEXOSIS OF THE CERVIX. 151 

culty in passing the sound, as this may arise from malpositions of 
the uterus, or from inexperience on the part of the operator. 

Prognosis. — In uncomplicated stenosis the prognosis is favor- 
able, operative interference usually being successful in removing 
the obstruction. Should the case be complicated with anteflexion 
or with pelvic peritonitis, the probability of effecting a cure is less 
favorable. 

Treatment. — This may be either by (a) Dilatation, or (ft) In- 
cision. 

Dilatation may be accomplished either by the use of the 
sound, tents, or dilators: but owing to the ease with which the 
cervical canal again contracts, the result obtained by these meth- 
ods are transitory, and a cure is seldom effected. 

To dilate with sounds, a set of graduated steel sounds are the 
best. A small one being passed, it is left in position a fev mo- 
ments, when the next larger is used in the same maimer, and so on 
as far as desired, being careful not to carry the dilatation too far 
at one sitting. 

Sponge, sea-tangle and slippery-elm tents are used, but I pre- 
fer the latter, as being more uniform and less liable to cause 
inflammation or septicaemia. 

There have been many forms of expanding instruments 
invented for dilatation of the cervix, but I much prefer the Moles- 
worth's acme dilator, though I think any such instrument is of 
little practical use in the treatment of stenosis. The subject of 
dilatation of the cervix is more extensively noticed in the chapter 
on Instrumental Examination, to which the reader is referred. 

Incision may be accomplished either by the knife, or by scis- 
sors. Several varieties of single and double-bladed knives, known 
as metrotomes, or hvsterotomes (Fig. 117) have been devised. A 




Fig. 117. — Hysterotome. 

single-bladed uterotome is employed in the following manner: 
The patient being placed upon her left side, the instru- 
ment is introduced without a speculum, and. guided by the index 
finger, it is passed almost to the internal os. when the blade is 
thrown out and the instrument withdrawn, pressure being increased 
gradually so that the incision is deeper at the external than at the 
internal os. The instrument is then re-introduced and a similar 
incision made on the opposite side. Both incisions are made at 






152 



A TEXT-BOOK OF GYNECOLOGY. 



once with the double-bladed hysterotome. Sometimes it is neces- 
sary to dilate with a tent before the hysterotome can be used. 

Dr. Marion Sims substituted the scissors for the knife. His 
method was as follows: The patient being placed in the semi- 
prone position, the speculum is introduced and the uterus is 
grasped with the volsella. One wall is then cut with a pair of 



Fig. 118.— Peaselee's Uterotome. 

long scissors, one blade of which is passed into the cervical canal 
until the outer blade reaches nearly to the base of the vaginal por- 
tion, and the incision is made. Then the opposite wall is divided 
in the same manner. Sims' uterine knife is then passed up and the 
tissues above the reach of the scissors are cut, including, if neces- 
sary, the os internum. A roll of carbolized cotton is then satu- 
rated with glycerine and introduced into the wound, and a vaginal 
tampon applied. The tampon should be removed on the following 
day, and on the third day the cotton dressing should be renewed, 
which must be repeated every other day in order to prevent a re- 
turn of the stenosis. The patient should keep her bed until the 
dressings are permanently removed. 

Thomas recommends the following simple modification of the 
above methods: (1) Make a very superficial incision through the 




Fig. 119.— Thomas' Glass 
Cervical Plug. 




Fig. 120. 



-Wylie's Cervical 
Plug. 



submucous layers of the parenchyma from the os internum through 
the whole course of the canal, and place within the canal a roll of 
cotton saturated with a weak solution of persulphate of iron. 
This may be allowed to remain in place for forty-eight or fifty-six 
hours. At the end of a fortnight a stem of glass (Fig. 119) or 
vulcanite (Fig. 120) may be inserted. 

t) Diseases of Women, p. 591. 



CHAPTER XVI. 



LACERATION OF THE CERVIX. 



As long ago as 1855 Sir James Simpson recognized the fact 
that a torn cervix was "a most common cause of aggravated cer- 
vical disease." But it was nearly ten years later that Dr. Emmett 
first attempted to remedy the condition by a plastic operation, and 
as late as 1869 he published his first paper calling the attention of 
the profession to the etiological importance of these lesions, and 
to his method of operating for their cure. To-day this operation 
is acknowledged as one of the most important in minor gynecolo- 
gical surgery, and while there can he no question as to its frequent 
abuse by ignorant or designing practitioners, it. nevertheless, has 
been, and doubtless will continue to be, a boon to many suffering 
women. 

Pathology. — Laceration of the cervix may be either uni- 
lateral or single (Fig. 121), bilateral or multiple (Fig. 122), and 




Fig. 121.— Single Laceration 
tenaculum. (Emmett.) 



ips are held apart with a double 



may divide only the infra-vaginal cervix, or a small portion of it. 
or may extend more or less above the vaginal attachments, in which 
latter case a cicatrix is formed which draws the cervix to one side, 
or sometimes even backward or forward. 

The most frequent seat of the laceration is on the left side of 



154 A TEXT-BOOK OF GYNECOLOGY. 

the anterior lip, which is due to the fact that the pressure of the 
long diameter of the head is most often in that direction. The 
chief pathological changes are those which result secondarily from 
the laceration. The uterus usually becomes prolapsed and the 
lips of the cervix everted on account of the traction of the 
vaginal insertion. Thus the mucous lining becomes exposed, and 
friction against the vaginal walls and contact with the vaginal se- 
cretions, together with injuries from coition and other sources, 
give rise to erosions, granular inflammations, and even to cystic 
degeneration of the entire vaginal portion of the cervix. Very 
frequently, however, these complications do not occur owing to the 
fact that the eversion is prevented by cicatricial tissue in the cleft 
of the laceration which holds the edges in apposition, and thus 
preserves the normal outline of the cervix. 

Retroflexion is a common consequence of laceration, and pel- 
vic cellulitis often occurs, being generally situated between the 




Fig. 122.— Multiple or stellate laceration. (Emmett.) 

folds of the broad ligament at the side of the laceration. Invo- 
lution is almost invariably delayed by deep lacerations, so that 
the condition known as subinvolution marks a majority of cases. 

Etiology. — Very rarely is a laceration of the cervix caused 
by anything else than labor at or near full term, but it may result 
from abortions, or from the passage of polypi, fibroids, or even 
from the passage of large, firm clots during menstruation. During 
labor it would naturally be supposed that a laceration would be 
most apt to occur in a rapid delivery where the os had not had 
time to properly dilate, but Dr. Emmett says that " lacerations are 
most often the result of tedious labors.' 1 

Symptoms. — The objective sign of a laceration and its com- 



LACERATION OF THE CERVIX. 155 

plications have already been mentioned. The subjective symptoms 
are not pathognomonic, and depend chiefly upon the secondary dis- 
orders and complications which ma}' prevail. It is now a well estab- 
lished fact that lacerations of the cervix in and of themselves do 
not produce any symptoms. Cases are known where deep lacera- 
tions have been present many years without giving rise to any 
symptoms whatever, owing to the fortunate fact that the usual 
sequelae of laceration did not follow. 

The symptoms are, therefore, for the most part, those which 
are described under chronic metritis, sub-involution, retroflexion, 
granular inflammation of the os, etc. Leucorrhea, pain in the 
small of the back, bearing-down pains, irregular menstruation, 
Menorrhagia, inability to stand or walk, are almost always found, 
but any or all of these symptoms may be absent. In some cases 
reflex neuroses are manifest, and the symptoms above mentioned 
may or may not be present. Then we may have local neuralgia, 
with excessive tenderness of the parts, or sympathetic neuralgia 
in other parts. One case is reported where cataleptic convulsions 
were present, and could be produced by pressing the finger into 
the angle of the laceration, but they did not occur from any other 
manipulation of the cervix. Sometimes the symptoms are those 
of an hysterical nature only. I had such a case last year, which 
came to me from the private hospital of a distinguished gynecolo- 
gist in one of our large cities. He had made the operation, but 
while he claimed union to have been complete, the patient grew 
worse rather than better. The doctor then desired the patient to 
allow him to operate for a slight laceration of the perineum, which 
she declined, and, leaving the hospital, put herself under my care. 
An examination revealed the fact that the operation had been a 
total failure. After a few weeks' preparatory treatment I made 
a successful operation, and six weeks later sent the patient home 
entirely cured, and she so remains. Her symptoms were solely 
of an hysterical nature, and confined to the motor sphere, the sen- 
sory nerves being but little affected. It is probable that in such 
cases the symptoms arise from constriction of the ends of the 
nerves in the cicatrix of the laceration. 

Diagnosis. — A careful physical examination can leave little 
doubt as to the presence of the laceration. Sometimes, when the 
lips are considerably everted and the cervix thickened, the diagno- 
sis can be made certain only by drawing together the everted lips 
with a pair of tcnacula, when the laceration will be plainly seen. 
The presence of the laceration being established, the next question 
is to ascertain the character and extent of the complications, which 
is of the utmost importance before operative measures are adopted. 

Prognosis. — Generally, if the operation is properly per- 



156 A TEXT-BOOK OF GYNECOLOGY. 

formed, union takes place without difficulty; yet it is sometimes 
necessary to repeat the operation, and in some cases the parts fail 
to unite in spite of the most careful treatment. It is usually con- 
sidered that recent cases are more amenable to treatment than 
those of very long standing, and in those where granulations are 
extensive or other important complications are present the prog- 
nosis should be guarded. In such cases the operation forms only 
a part of the treatment and cannot be expected to relieve all the 
morbid phenomena that may be present. Septic inflammation has 
been known to follow the operation, and several fatal cases are 
reported. 

Treatment. — In case the laceration is discovered at the time 
of delivery, spontaneous union may possibly be brought about by 
proper treatment. Hot water injections should be used twice daily 
for several' days, and kept up once a day for at least two or three 
weeks. Once a day the injection of hot water should- be followed 
by an injection of about four ounces of tepid water in which has 
been placed one drachm of fluid calendula and a half ounce of glycer- 
ine, the solution being slowly thrown directly upon the wounded tis- 
sues. If the case is of too long standing to be benefited by this 
treatment it becomes necessary to resort to Emmett's operation, 
otherwise known as hystero-trachelorrhaphy. The operation, how- 
ever, should not be made if the laceration has produced no dis- 
turbance of the system of any kind; and if it be complicated with 
pelvic inflammation, the operation should not be attempted until 
this condition has been reduced as far as possible by proper local 
treatment, which is elsewhere considered. In some cases, even 
after having received treatment, cellulitis may exist to such 
an extent as to render it quite unsafe to attempt the operation, 
though Dr. Goodell and others consider cellulitis an indication 
for the operation, and do not hesitate to operate on account of its 
presence. 

Having decided upon the operation, the patient should be 
placed upon a preparatory treatment for at least two or three 
weeks. She should use hot water injections daily, and any local 
disturbances should receive appropriate treatment, with a view of 
reducing any inflammation that may be present to the minimum. 
For this purpose I generally use the following : 

R— Fluid Hydrastis, §i; 
Fluid Calendula, |i; 
Glycerine, fvi. Mix. 

Sig. Apply on a pledget of cotton once a day, or put one tablespoonf ul 
in four ounces of warm water and use as an injection. 

The patient should also be placed upon the appropriate con- 
stitutional remedy. 



LACERATION OF THE CERVIX. 157 

Details of the Operation. — The operation consists in 
simply paring the edges of the laceration, and bringing them 
together by means of sutures, but this process is not always as 
simple as it may appear. The operation should be made within 
from three days to a week after the menstrual period. The 
bowels should be moved by an enema about an hour before the 
operation, and the bladder emptied the last thing. 

I believe it is customary to use an anaesthetic, but I have 
never done so, nor do I believe it necessary or advisable, except, 
perhaps, in cases of very nervous women. The operation is com- 
paratively painless, and the patient's sufferings are chiefly from 
fatigue and the pressure of the speculum. 

The patient being placed in the semi-prone position, Sims' 
speculum is introduced and the parts brought into view. Some 
operators prefer the lithotomy position. The cervix is then fixed 
by a double tenaculum (Fig. 123) and brought down so that it can 




Fig. 123. — Emmett's Double Tenaculum. 

be reached, but drawing the uterus down to the vaginal orifice is 
unnecessary, and should not be practiced. Having been careful 
that the tenaculum is so placed as not to interfere with the opera- 
tion, it is given to an assistant, and with it he holds the uterus 
steady during the operation. Dr. Emmett slips a uterine tourni- 
quet over the cervix, to control the hemorrhage; a rubber ring 
can be used for this purpose, but I have never found either of 
these necessary. If the hemorrhage proves considerable, an injec- 
tion of hot water will control it, and in exceptional cases a stream 
of hot water can be kept flowing over the parts by means of a 
fountain syringe. The next step, after drawing down the cervix, 
is to place the edges of the laceration in apposition, in order to 
estimate the amount of tissue necessary to be cut away. The sur- 
faces then are freely pared with the knife or scissors. Most oper- 
ators prefer the scissors, but I always use Sims' rotating knife 
(Fig. 100). Enough tissue should be removed to include all 
irregularity of surface and any diverging fissures, leaving a uni- 
form, smooth cut surface on each side, and at the same time being 
extremely careful that every trace of cicatricial tissue in the cleft 
of the laceration be removed, though efforts should be made to 
avoid cutting deep enough in the fissure to wound the large vessels 



158 



A TEXT- BOOK OF GYNECOLOGY, 



in that locality (Fig. 124). As Dr. Comstock well remarks, 
"the introduction of the suture is the most difficult part of the 
operation." The suture should be of silver, and about eight 
inches in length. I prefer the lance-pointed needles, but Dr. 
Emmett recommends the round needles, as they make a smaller 
hole and are followed by less hemorrhage. The needles should be 




Fig. 124.— Operation for lacerated cervix, a, b, extent of denuded 
surface. 

fixed in a Russian needle-holder (Fig. 125) and passed in just at 
the upper edge of the fissure, holding the part firmly by means of 
a blunt hook (Fig. 104), which makes counter-pressure. The 
suture is drawn half through, but is not firmly twisted until the 




Fig. 125. — Russian Needle-Holder. 

lower sutures are all in, but after each suture is placed the ends 
should be lightly twisted and handed to an assistant to hold out of 
the way. These should be about one-third of an inch apart. In 
the lower sutures it is usually necessary to pass the needle through 
one lip and then through the other, being careful to enter at a 
corresponding point, so that there may be no puckering. Some 
operators prefer to use Jackson's cervical needle, which possesses 
some advantages over the ordinary needle. The shape of this 
needle and the method of using it is illustrated in Fig. 129. 



LACERATION OF THE CERVIX. 



159 



All the sutures being placed, they are firmly twisted in the 
order they were introduced, and the ends either cut off or left to 
be brought out at the vaginal orifice, where they should be tied 




Fig 126.— Extext of denuded surface and course of sutures accord- 
ing to Emmett {Emmett). The sutures are passed in order 1, 2, 3, 4; 
the course of suture 4 alone is indicated by letters a, b, c, d. 




Fig. 127.— Mode of passing sutures; 
a, b, denuded surface as in Fig. 124. 



The sutures 
numbered. 



are passed in order as 



Fig. 128. — Appearance of cervix 
when sutures twisted up, They 
are left long so as to extend to 
vaginal orihce and are removed 
in order as numbered. 



160 



A TEXT-BOOK OF GYNECOLOGY. 



together and wrapped with wadding. I think, all things con- 
sidered, that it is best to follow Dr. Emmett's plan and cat the 
sutures short. The sutures should be removed in order from 
above downward, about the eighth or ninth day. If it is found 
that the edges have not perfectly united, the lower sutures may be 
left a few days longer. The patient should remain in bed until 
after the sutures have been removed, and meanwhile, after the 




Jackson's Cervical N< 



second day, she should receive an injection daily of tepid water, in 
which has been placed a few drops of fluid calendula. 

Of course, I have given only the method of treatment for a 
simple laceration. Should the laceration be double, the opposite 
side is treated in like manner, and if complicated fissures occur 
which are too much for the operator's ingenuity and skill, I would 
refer him to Dr. Emmett's exhaustive articles on the subject. 



CHAPTER XVII. 



CHRONIC CERVICAL ENDOMETRITIS. 

Synonyms. — Endo-cervicitis ; chronic cervical catarrh. 

Definition. — A chronic inflammation of the mucous lining 
of the cervical canal. 

Frequency. — This affection is the most frequent disease of 
the female pelvic organs, and exists to a greater or less extent as 
a complication of other pelvic diseases. On account of its fre- 
quency, Dr. Thomas regards it as a normal condition, "at any 
rate, in the married women," and this may be true so far as slight 
erosions and mucus discharges are concerned, but it certainly is 
not true when we consider the severer forms of the disease which 
we are called upon to treat. Chronic inflammation may exist 
either in the cervix or the body of the uterus, and limit itself to 
either locality, though it does frequently extend and involve more 
or less of the entire uterine lining. 

Pathology. — This condition is essentially a glandular disease, 
the first pathological change being a hyperemia of the follicles of 
the cervical canal, which are called by some the glands of Nabothi. 
They next become swollen, enlarged, elevated, and their mouths 
dilated, and pour forth an increased quantity of glairy mucus, 
which soon becomes thick and tenacious, and finally yellow, and 
frequently tinged with blood. The possible amount of this secre- 
tion can be realized only when we remember that the rugae, or 
plicated folds of the mucous membrane of the cervix, create a 
very much greater secreting surface than the length of the cervix 
would indicate, and that within these folds there are estimated to 
be about ten thousand of the follicles or glands Nabothi. The 
secretion is acrid and corrosive in its character, and it has until 
quite recently been supposed that this secretion caused a disinte- 
gration of the epithelium, giving rise to an abrasion, which finally 
affects the deeper tissues, and the papillae, becoming hypertro- 
phied, project from the surface, giving it a granular appearance, 
hence the name of granular degeneration. 

The recent investigations of Ruge and Viet have shown that 
the condition is not one of degeneration and destruction of tissue, 
but a proliferation of tissue. The mucous membrane is not 
abraded, the apparently raw surface being covered by epithelium, 
and the granulations are new formations, having no connection 

161 



162 A TEXT-BOOK OF GYNECOLOGY 

whatever with the papillae of the mucous membrane. There is 
great proliferation of the cylindrical epithelium and glands, which 
displaces the pavement epithelium, and appears as protuberances, 
while the surface is thrown into numerous folds, producing gland- 
ular recesses and processes. 

' ' If the recesses be long and narrow, the surface is split up 
into distinct papillae; this constitutes the papillary erosion. If the 
ducts of the glandular recesses become obliterated, the secretion 
will distend the gland below and produce retention-cysts; these 
will increase in size, and may come to the surface and burst. Thus 
there is formed the follicular erosion. The raw-looking surface is, 
therefore, a newly-formed glandular secreting surface, resembling 
in structure the cervical mucous membrane. This addition to the 
extent of secreting surface increases the leucorrheal discharge, 
which is the leading symptom." (1) 

The proliferation is usually more manifest around the external 
os, causing red granular patches of irregular outline and extent, 
and which appear well defined from the paler normal mucous 
membrane which covers the cervix. This condition has usually 
been termed "ulceration," but as there is no destruction of 
tissue, the process is not one of "ulceration," and, as Hart and 
Barbour remark, "that term should be abandoned." 

Dr. Thomas devotes a chapter to the description of these con- 
ditions, apart from chronic cervical endometritis, denominating 
them respectively as "granular and cystic degeneration of the 
cervix," the former being the papillary form. From the recent 
investigations above mentioned, it is evident that such a classifica- 
tion is entirely erroneous, and that we must consider the condi- 
tions referred to as simply an extension and aggravation of the 
catarrhal condition of the cervix, which may be present to a 
greater or lesser degree throughout the entire cervical canal. Not 
infrequently an eversion of the cervical mucous membrane takes 
place, especially when laceration is present, in which case the con- 
stant irritation to which the everted surface is subject only serves 
to aggravate the condition. Sometimes the proliferations become 
excessively luxuriant, having more or less the appearance of 
fungus growths, and have been termed "cockscomb granulations." 

In cases of long standing, a hyperplasia of the connective 
tissue also occurs, and this complication may gradually involve 
more or less of the entire uterine parenchyma, until the primary 
catarrhal condition is insignificant in comparison with the 
chronic metritis which has become established. So, also, in cases 
where the inflammation has extended to the connective tissue, may 
we have destruction of the epithelium and a true ulcerative pro- 

1) Hart and Barbour, Op. Git., p. 278. 



CHRONIC CERVICAL ENDOMETRITIS. 163 

cess, differing entirely from the catarrhal condition already con- 
sidered. 

Etiology. — There are both predisposing and exciting causes. 
The chief predisposing causes are, according to Thomas (1): Natural 
feebleness of constitution; the existence of a cachexia, as tubercu- 
losis or scrofula; impoverishment of the blood from chlorosis or 
other cause; prolonged mental depression; insufficient nutriment; 
excessive lactation; frequent parturition; subinvolution; styles of 
dress which depress the uterus; want of exercise and fresh air. 

The chief exciting causes are injuries to the cervical canal 
during parturition, especially laceration of the cervix. Next 
comes abuse of the sexual function; cold injections to prevent 
conception; the use of the sound and other methods to produce 
abortion; the use of tents and pessaries; displacements of the 
uterus; and last, but not least, an extension of vaginitis, especially 
gonorrheal, upward, and extension of endometritis, especially 
puerperal, downward. 

Symptoms. — The chief symptom, and that first manifest, is 
leucorrhea. Often subjective symptoms are entirely wanting for 
a long time, and the gradually-increasing leucorrhea! discharge is 
all that calls attention to the condition. This in appearance 
resembles the unboiled white of an egg, being a clear, glairy, 
transparent fluid. Sometimes it is more white and opaque, and is 
frequently tinged with blood. The patient soon begins to com- 
plain of a pain in the back and loins, especially when exercising, 
and a continual, heavy, dragging sensation about the pelvis. If 
the endometrium becomes involved, or hyperplasia exist to any 
extent, the menstruation becomes irregular, the quantity being 
usually increased. 

After a time, the patient usually becomes anaemic, weak and 
nervous from diminished nerve force and from malnutrition con- 
sequent upon derangement of digestion. Should the disease 
extend to the endometrium or uterine parenchyma, the symptoms 
become more numerous, and are to a greater extent connected 
with the secondary complications, rather than with the primary 
disease. This is true, also, when vaginitis or cystitis occur to 
render the disease more intractable and distressing. 

Physical examination reveals to the touch a more or less 
patulous condition and irregular shape of the cervix, if the patient 
has borne children, being always worse if there has been laceration 
of the cervical canal. In nulliparae the only change may be an os 
somewhat enlarged, with its lips slightly puffed. 

Examination with the speculum shows extending from the os ' 
the characteristic albuminous discharge, which is so tenacious that 



1) Diseases of Women, p. 



164 A TEXT-BOOK OF GYNECOLOGY. 

it is removed with great difficulty. After the parts have been 
cleansed, the patulous os is seen, and more or less of the red, 
granular surface, the extent of which varies according to the 
amount of the os externum which is involved in the catarrhal pro- 
cesses. In case the disease is confined to the cervical canal, and 
there is no eversion, the external os may present a normal appear- 
ance, and we may diagnosticate the condition only by the charac- 
teristic discharge and the constitutional symptoms which are 
present. 

Diagnosis. — The most important diagnostic question to settle 
is, whether or not the endometrium is involved; and often it will 
be found impossible to come to a satisfactory conclusion. If 
endometritis is present, the sound will usually reveal a consider- 
able degree of sensitiveness, and the discharge be less albuminous 
and tenacious in its character, and more often purulent and streaked 
with blood. Generally, too, the constitutional symptoms are more 
numerous and of a graver nature. If the cervix is much thick- 
ened and indurated, and especially if at the same time the patient 
complains of burning or lancinating pains, carcinoma should be 
suspected. 

Pkognosis. — The duration of the disease depends upon the 
extent of surface involved, the condition of the general health, 
and the character of the complications which may be present. In 
case of any considerable severity the course is usually tedious and 
discouraging, in spite of treatment. Dr. Thomas says that " when 
there is little granular disease, and a large amount of thick, resist- 
ing mucus hangs from the cervical canal, the prognosis, according 
to my experience, is very doubtful, and sometimes hopeless, unless 
very radical measures be adopted. In all cases the prognosis 
should be guarded, as at the best they may require treatment for 
months, and even when apparently cured the condition is liable to 
return upon very slight occasion." 

Treatment. — The treatment of a case of chronic cervical 
endometritis will depend very largely upon the constitutional con- 
dition of the patient. Where she has become weak and anaemic, 
hygienic measures are of great importance. A nourishing diet, 
fresh air and sunshine, with appropriate exercise, proper clothing, 
change of scenery, limitation of sexual indulgence, and a proscrip- 
tion of all improper efforts to prevent conception, are conditions 
which should not be forgotten. In the constitutional treatment 
the indications for remedies will depend entirely upon the symp- 
toms of each individual case. The remedies chiefly required are 
Sepia, Calcarea carb., Fcrrum, Mercurius, Kali iod., Sulphur, 
etc. For their special indications the reader is referred to the 
chapter on Lcucorrhea. The local treatment of these conditions is 



CHRONIC CERVICAL ENDOMETRITIS. 165 

of great importance, while undoubtedly it has been abused by 
some physicians, and patients have suffered therefrom, yet chronic 
cervical endometritis is not a self -limiting disease, and is of so 
purely a local character that I think but few cases would ever 
recover without appropriate local treatment. 

For purposes of cleanliness the patient should use daily an 
injection of tepid water and castile soap, but, except where the 
surface of the os is implicated, medicated vaginal injections are of 
but little value. If the os is more or less covered by catarrhal 
erosions, some benefit may be derived from the use of the follow- 
ing prescription : 

I£. — Fluid Hydrastis, |i; 
Fluid Calendula, §i; 
Glycerine, |vi. Mix. 

Sig. One tablespoonful in four ounces of tepid water as an injection 
once or twice a day. 

Much more benefit, however, is usually derived from the 
direct application of the above medicines on a cotton tampon. 
After considerable experience I am convinced that the application 
of simple glycerine will, in most cases, answer a better purpose than, 
or, at least, do equally as well as, the same combined with Hydras- 
tis or any other medicine. In speaking of the use of glycerine 
Dr. Ludlam says (1) "This substance has the power of causing a 
free discharge of serum from its engorged capillaries, and thus of 
removing an incidental cause which not infrequently serves of 
itself to perpetuate the disease. 

The determination of blood to the dependent cervix, and its 
stasis therein, is a prime cause of the excessive and abnormal 
secretion from the cervical glands. If we relieve this local 
embarrassment of the circulation, it is like extracting a splinter 
from the flesh in a case of irritative fever. Moreover, the expedi- 
ent is simple, available, and harmless. It neither interferes with 
the use of internal remedies nor antidotes them. It has no inju- 
rious effect upon menstruation, nor does it entail any reflex or 
remote consequences upon other organs, which may or may not be 
implicated." 

With these conclusions I can fully agree. There are cases, 
however, in which the use of simple glycerine proves inefficient. 
In such I prefer to apply iodine and glycerine, 20 grains to the 
ounce, using a camel's-hair brush, or a cotton-wrapped probe for 
the purpose, which can be passed up as far as the internal os, and 
then withdrawn, after which a tampon of glycerine may be ap- 
plied. In other cases glyceroles of Hydrastis, Sanguinaria, Pinus 
canadensis or Tannin may answer better. The method of prepar- 

1) Diseases of Women, Sixth ed., p. 463. 



166 A TEXT-BOOK OF GYNECOLOGY. 

ing a tampon or "glycerine plug," is described in the chapter on 
Ovaritis. 

When the disease fails to respond to ordinary treatment, and 
the mucous follicles are the seat of an aggravated inflammatory 
condition, which has resulted in a cystic degeneration, or where 
the granulations have become very exuberant, it may become 
necessary to destroy entirely the diseased surface, in the hope that 
nature will furnish reparative covering, as it usually does. Some- 
times this may be done with iodine or carbolic acid, but more often 
nitric acid will be required. The parts must be freely touched, 
using a firm wooden toothpick, or a cotton-wrapped probe. The 
parts should first be thoroughly cleansed, and it is well to pack a 
pledget of cotton well soaked in bicarbonate of soda solution in 
the vagina beneath the cervix, in order to protect the vaginal 
mucous membrane from injury. After the acid has been applied 
the cotton should be removed, and the cervix syringed with cold 
water, after which a glycerine plug is applied, and removed daily 
for a week or more. Great caution should be observed that con- 
traction of the cervical canal does not take place. Probably the 
best method for destroying the unhealthy surface is to mechani- 
cally scrape and tear away the enlarged mucous glands and vege- 
tations by means of a curette, after which carbolic acid should be 
carefully applied, and the case subsequently treated as one of 
cervical endometritis. Sometimes it is necessary to repeat the 
operation after two or three weeks, in which case it may be better 
to use the nitric acid than the curette. 

The reader is also referred to Chapter XXI, on the " Treat- 
ment of Chronic Metritis, Endometritis and Peri-uterine Inflamma- 
tions by Electricity." 






CHAPTER XVIII. 



CHRONIC CORPOREAL ENDOMETRITIS. 

Synonyms. — Chronic endometritis; chronic uterine catarrh; 
internal metritis; uterine leucorrhea; blennorrhea of the uterus. 

Acute corporeal endometritis is of rare occurrence, except at 
the puerperal period and in the course of acute infectious diseases, 
and, therefore, Avill not be considered in this work. 

Definition. — A chronic inflammation of the lining membrane 
of the uterus above the os internum. 

Frequency. — Chronic corporeal endometritis is not nearly of 
so frequent occurrence as the cervical form, yet it is probably a 
much more common disease than has generally been supposed. 
By some authors it is claimed that endometritis is always more or 
less general, that it never involves either the cervix or body ex- 
clusively, but that wherever the disease may originate, it sooner 
or later involves more or less of the entire uterine cavity, the 
os internum being no bar to its extension either upward or down- 
ward. This may be true, yet from a practical standpoint, we may 
consider the disease as being located at the point where it pre- 
ponderates, not allowing for any comparatively slight extensions 
beyond the internal os. At the same time, we must admit the 
relative frequency of general endometritis, where both the cervix 
and body are implicated. 

Pathology. — According to the recent investigations of Carl 
Ruge, De Sinety and Olshausen, there can be distinguished three 
pathological types of endometritis, according to the tissue in- 
volved. These may be designated as the glandular, the interstitial 
and the embryonic forms; but it must be understood that no one 
of these forms exists absolutely independent of the others, as it is 
probable that the process is never confined to but a single kind of 
tissue. 

In the glandular form there is proliferation of the glandular 
epithelium, and the cells of acini increase in size, thus causing 
hypertrophy; or, according to Ruge, instead of hypertrophy, the 
glands may increase in number, k ' either by the formation of 
diverticuli in the old glands, or by new depressions in the surface 
of the mucous membrane." In the glandular form, leucorrhea is 
said to be the chief symptom. In the interstitial form, there is 
found a variety of structural changes, according as to whether the 

167 



168 A TEXT-BOOK OF GYNECOLOGY. 

cellular elements or the connective tissue are involved. The 
mucous membrane is at first swollen, vascular, soft and succulent, 
is smooth on its surface or roughened in spots, and is hypertro- 
phied to four or five times its normal thickness. Portions of this 
scraped away with a curette show under the microscope, according 
to Olshausen, ' ' great hypertrophy of the mucous membrane, with 
increase of all its elements; moderate dilatation of the lumina of 
the glands, enlargement of the blood-vessels, and marked cellular 
infiltration of the connective tissue." In this form, while the 
newly-formed connective tissue elements are soft and succulent, 
hemorrhages are frequent, and constitute the chief symptom of 
the interstitial variety. 

The embryonic form is described only by De Sinety. "In 
other cases," he says, " the vegetations are specially constituted 
of embryonic tissue, with few blood-vessels. There are only 
traces of the glands and some remains of more or less degenerated 
epithelium. We have to do with a truly inflammatory tissue, 
comparable to that which forms upon an exposed wound. At 
certain points there are islands of degenerated elements, which are 
not colored by reagents, and are analogous to those observed in 
foci producing pus. This degeneration of embryonic elements 
explains to us the abundance of the muco-purulent discharge 
observed during life." 

According to Winckel (1), "when the inflammatory process 
is long continued, the mucous membrane finally atrophies and be- 
comes thinned, the ciliae are lost, the gland cells, or even the entire 
glands, disappear, and at last the only covering to the inner surface 
of the uterus is a thin, smooth layer of connective tissue." 

Etiology. — The causes are both predisposing and exciting. 

Predisposing Causes. — Strumous, or tubercular diathesis; 
syphilis; chlorosis; exhaustion from parturition or lactation. 

Exciting Causes. — Acute endometritis; cervical endometritis; 
suppression of the menses from exposure; obstruction to the escape 
of the menstrual fluids; abortion and parturition, especially when 
any of the secundines remain; or from getting up too soon; sub- 
involution; displacements, especially retroflexion and prolapsus, 
which give rise to congestions; pelvic peritonitis; excessive sexual 
indulgence, or ungratified sexual desire; tumors in the uterine 
cavity or walls; injuries from sounds, tents, etc.; injuries from 
efforts to produce abortion; extension of vaginitis, specific or 
simple. 

Symptoms. — Leucorrhea and menorrhagia are the leading 
symptoms, but it is seldom that both occur in the same case, as 



1) Winckel, Diseases of Women, p. 438. 



CHRONIC CORPOREAL ENDOMETRITIS. 169 

they arise from two distinct pathological types of the disease. 
(See Pathology.) 

Leucorrhea is the most important and most constant symp- 
tom. The discharge is watery and glairy, like starch-water, or it 
is purulent, and very commonly commingled with blood. It is 
always less thick, viscid and tenacious than cervical leucorrhea, 
but it must be remembered that cervical endometritis may always 
exist in the same case, and both uterine and cervical leucorrhea 
be present. The uterine secretion has an alkaline reaction, while 
that of the vagina is acid, yet we find that corporeal leucorrhea is 
much more acrid and irritating than cervical leucorrhea, and, 
though small in quantity, it frequently causes disagreeable and 
painful excoriations of the vagina and external genitals, producing 
a pruritus, and, by conveyance, it sometimes causes urethritis and 
blennorrhea in the male. 

Menorrhagia is frequently present. The flow appears too 
frequently, and is too free or too prolonged. Sometimes, after 
continuing for a few days, it will stop a few hours or a day and 
then return; occasionally the flow becomes continuous, and at 
greater or less intervals profuse and dangerous hemorrhages 
may occur. 

Dysmenorrhea may be present, from the hyperemia and 
swelling of the endometrium, from an accompanying stenosis or 
flexion causing obstruction, or from an exfoliation. Some author- 
ities consider the latter condition an evidence of chronic corporeal 
endometritis, but it will be best considered under the head of 
membranous Dysmenorrhea. 

Weakness, or pain in the back, a weariness and discomfort 
rather than an actual pain, is a frequent symptom. Sometimes 
there may be a dull, aching, dragging pain in the hips, or uterine 
or ovarian region, and frequently the patient complains of a burn- 
ing sensation across the hypogastrium. The pain, as a rule, de- 
pends more upon the complications that may exist than upon the 
endometritis. 

Digestive and nervous symptoms are almost invariably present 
in long-standing cases. The digestion is impaired, the appetite 
poor, and the patient becomes feeble and anaemic, especially in the 
hemorrhagic type. Neuralgic headache is frequently present, 
especially on the crown or left temple, and the patient may be 
more or less hysterical and become sad and despondent, amount- 
ing in some cases to melancholia. Tympanites is often present, 
and obstinate constipation is not unusual, both probably depend- 
ing upon a sympathetic disorder of the nerves governing peri- 
stalsis. Sterility is present in a majority of cases. This may be 
due either to the discharges destroying the vitality of the sper- 



170 A TEXT-BOOK OF GYNECOLOGY. 

matozoa, or to their entrance to the uterine cavity being mechani- 
cally prevented; or, should fecundation occur, retention and fixa- 
tion of the fertilized product fails to take place on account of the 
diseased condition of the endometrium; or, should the attachment 
be made, it may prove imperfect, and abortion result. Thus, as 
Hart and Barbour remark, u a vicious circle is produced. As 
mentioned under Etiology, endometritis frequently follows abor- 
tion; abortion, in its turn, frequently follows endometritis." 

Physical exploration does not reveal much that is reliable. 
The uterus shows greater depth and is more sensitive to the sound 
and to bi-manual touch, and the sound is frequently tinged with 
blood when withdrawn, the internal os is patulous, and at the ex- 
ternal os may be seen the characteristic discharge, usually mixed 
with that from the cervix. 

Diagnosis. — This can be established only by a careful con- 
sideration of the physical signs and subjective symptoms already 
mentioned, not forgetting the frequency of such complications as 
cervical endometritis, displacements, metritis, etc., which may 
serve to mask the symptoms of this disease. A curette may be 
introduced within the cavity of the uterus and sufficient of the 
diseased tissue be scraped away for microscopical examination, 
without injury to the patient. Such an examination would reveal 
large decidual cells or fragments of the villi of the chorion in a 
state of fatty degeneration, in case there were endometritis due to 
an incomplete emptying of the uterus after parturition. It would 
also serve to positively differentiate between endometritis and a 
commencing malignant disease, by establishing the presence or 
absence of the typical cells of either carcinoma or sarcoma. 

Prognosis. — Endometritis seldom results fatally, but it is 
generally protracted, and gives rise to anaemia and constitutional 
disorders which render life miserable. Some authors claim that 
the disease is incurable, but, although it is very intractable, 
many cases, if not cured, are at least greatly ameliorated under ap- 
propriate treatment, and remain so until the menopause arrives, 
which usually marks the end. The most difficult cases are those 
which occur in persons of a scrofulous, tubercular or syphilitic 
diathesis, or in those which are of gonorrheal origin. 

Treatment. — My remarks on the hygienic treatment of cer- 
vical endometritis are equally applicable here. Very nearly the 
same class of constitutional remedies, also, is required, for the in- 
dications of which reference is made to the chapter on Leucorrhea. 

Local Treatment. — The character of the local treatment to 
be employed in chronic corporeal endometritis, and the extent to 
which the treatment should be carried, are mooted questions, and 
their consideration is of the utmost importance. I am convinced 



CHRONIC CORPOREAL ENDOMETRITIS. 171 

that most of the heroic measures employed are a source of aggra- 
vation rather than cure. 

Intra-uterine injections as a means of medicating the interior 
of the uterus is an ancient method, having been advised and prac- 
ticed by Hippocrates, and alternately advised and condemned by 
his followers to the present time. On account of the pain and 
dangers which attend this method, and the fact that medicines 
may be applied to the endometrium in a much safer manner, it is 
at present rejected by most gynecologists in this country and in 
Europe. In case it is thought desirable to use intra-uterine injec- 
tions they should be made with a syringe provided with a double 
channel, so that the injected fluid may rapidly escape. Moles- 
worth's double cannulaand bulb intra-uterine syringe is the safest 
and best instrument of the kind that I have seen. Jennison's 
douche (Fig. 130) is also an excellent instrument. The remedies 




Fig. 130. — JennisoD's Douche. 

best employed in this manner are tincture of Iodine, or fluid 
Hydrastis. Dr. Hale recommends the following formula, which 
is also endorsed by other gynecologists: 

3- — Muriate hydrastis, gv. v; 
Glycerine, §ss; 
Water, §iss. Mix. 

One-half drachm to be used at a time, care being taken here 
as elsewhere that the temperature of the injections be not 
lower than 90 ° . Others recommend Iodized Phenol where the 
mucosa fungosa are present. It is best always to wash out the 
uterine cavity with warm water before making the injection, and 
be sure that there is no air in the syringe. The fluid should be 
injected very slowly, and the patient remain quiet in the recum- 
bent position for some time after. Unless the os be patulous it may 
be necessary to dilate before making the injection. 

The direct application of medicines to the diseased endometri- 
um by means of the applicator, or a swab prepared by carefully 
wrapping a probe with cotton, is a safer and more effective method, 
and is the one usually adopted by those who practice local treat- 
ment in this disease. The parts being exposed by a Sims' specu- 
lum, and the os dilated, if necessary, a cervical speculum is intro- 
duced. Through this a cotton- wrapped probe is carefully passed 



172 A TEXT-BOOK OF GYNECOLOGY. 

into the fundus and swept around slowly, to remove the mucus 
from the cavity. It is then withdrawn and another probe, simi- 
larly prepared, and saturated with the medicine to be used, is 
introduced and gently turned around and pressed against the 
uterine walls so as to squeeze out the medicine. The instrument 
and speculum are then withdrawn, and the patient left quietly in 
bed until the following day, and longer if any discomfort follow 
the application. Care must be taken that the cotton be firmly 
twisted on the applicator, so that there may be no risk of its slip- 
ping off, and yet its outer layers must remain loose enough to 
absorb fluid easily and freely. The same medicines may be used 
as in intra-uterine injections. The use of strong caustics cannot 
be too severely condemned. Dr. Thomas says (1) "I would 
advise against the use of strong caustics in endometritis occurring 
above the os internum, upon the ground that I have not seen them 
accomplish as much good as the same substance in alterative 
strength. I would not, in the condition which we are considering, 
employ the nitrate of silver in solid form, pure chromic acid, or 
fuming nitric acid." 

There are, however, some old-school gynecologists who rec- 
ommend these substances, and I have myself seen one case of gon- 
orrheal endometritis where a fatal peritonitis resulted from an 
intra-uterine injection of chromic acid, made by a so-called 
homeopathic physician. Curetting the endometrium is now a pop- 
ular method of treatment, it having been established that ' ' after 
the mechanical removal of the old diseased mucous membrane, a 
new endometrium of relatively normal functional activity is 
formed." Hart & Barbour recommend curetting, followed by 
the application of carbolic acid, "if there be roughness of the 
endometrium, or if there has been a recent miscarriage or confine- 
ment." The operation should not be performed if there be 
present any active pelvic inflammation. Thomas' dull wire curette 
(Fig. 67) is the safest and most satisfactory instrument to use. 
Sims' speculum having been introduced, and the uterus drawn 
clown and held firmly by the volsella, the curette, previously 
dipped in carbolized oil, is carried into the uterine cavity. The 
anterior wall is first scraped from the fundus downward, and then 
the posterior wall is treated in like manner. But slight pressure 
should be made unless the instrument be felt to slip over the 
irregularities of the mucous membrane without removing them. 
The blood and mucus is then carefully wiped away by means of 
a cotton-wrapped probe, which process is repeated several times if 
the first is not sufficient. The medicine, either a solution of car- 
bolic acid, tincture of Iodine, Calendula or Hydrastis, is then 

1) Diseases of Women, p. 265. 






CHRONIC CORPOREAL ENDOMETRITIS. 173 

introduced on a cotton-wrapped probe, after which a tampon of 
glycerine is applied to the os and cervix for twenty-four hours, the 
patient keeping her bed for at least a week after the operation. 
Dr. Apostoli has originated a new treatment of endometritis and 
other pelvic inflammations with electricity, which promises to be 
of great value. A detailed description of this method of treat- 
ment is given in a succeeding chapter, to which the reader is 
referred. 



CHAPTER XIX. 



ACUTE METRITIS. 



Synonyms. — Congestive hypertrophy; inflammation of the 
uterus. 

Definition. — An acute inflammation of the muscular wall of 
the uterus. 

Pathology. — (1) "The uterus may swell to the size of a 
goose egg; it is thick, hypereemic, succulent, almost doughy. 
The whole substance is tumefied, infiltrated with serum, and 
hypersemic, and echymoses are scattered throughout its tissues. 
Between the muscular fasciculi pus-corpuscles are found, usually 
only in a small quantity, in some spots more abundantly. The 
endometrium, as a rule, is also inflamed, and the serous envelope 
always participates in the change, being either hyperaemic or 
bathed in pus, or else covered with flocculent deposits, or even 
thickened." 

Etiology. — Acute metritis may be of puerperal origin, in 
which case it results from taking cold, or from an accident during 
parturition, causing endometritis and the extension to the paren- 
chyma, or any cause which results in an absorption of septic 
matter. 

The non-puerperal variety may be caused by taking cold dur- 
ing menstruation, from gonorrheal infection, excessive and forcible 
coition, injury during surgical operations, or from the careless use 
of the sound, as well as from sponge-tents, intra-uterine pessaries, 
intra-uterine injections, etc. 

Symptoms. — Rigors, with high temperature and severe pain, 
are the chief symptoms. The pain is located in the pelvis or 
abdomen, or both, and, when the peritoneum is involved, it may 
shoot all over the abdomen. It is worse from the slightest motion, 
from coughing, sneezing, or even speaking. Evacuation of the 
bladder or rectum causes acute pain. At the same time there is 
a sensation of fullness, heaviness and burning throughout the 
pelvis. Constipation is usually present at first, but diarrhea, with 
more or less tenesmus of the rectum and bladder, soon follows. 
Nausea and vomiting are common symptoms. The menses are 
either suppressed, if caused by taking cold during menstruation, 



1) Schroeder; Ziemssen, Vol. X, p. 



ACUTE METRITIS. 175 

or they are scanty, or menorrhagia occurs. In the puerperal 
variety the lochia are suppressed. 

Physical examination reveals the vagina to be hot and dry, 
the uterus swollen and very sensitive, either from external pres- 
sure or internal manipulation, the bi-manual examination causing 
excessive pain. 

Under appropriate treatment, the symptoms may disappear 
within a few days, and the patient be entirely well, but more often 
chronic metritis is developed, with its usual history; or, rarely, 
the acute condition may terminate in an abscess, and perforation 
take place in adjacent organs, or through the abdominal walls. 
Should rupture occur into the peritoneal cavity, it is almost 
invariably fatal. Often, after the abscess has run its course, a 
chronic metritis remains, not infrequently complicated with pelvic 
cellulitis, especially in cases of gonorrheal origin. 

Diagnosis. — The uniform increase in size of the uterus, 
and the great sensitiveness to touch and motion, together with 
other physical signs and subjective symptoms above mentioned, 
will usually determine the presence of parenchymatous inflamma- 
tion. Metritis is often complicated with endometritis, or with 
peritonitis and cellulitis, and in such cases it is quite difficult to 
differentiate, or to decide in which of the tissues the inflammation 
predominates. 

Prognosis. — Acute metritis is always a grave disease, and 
the gravity increases in proportion to the extent that the peri- 
toneum is implicated. Resolution may take place and the patient 
make a complete recovery, but chronic metritis is very liable to 
ensue, or an abscess may occur, and thus life be greatly en- 
dangered. 

Treatment. — The patient should at once be placed in bed 
and absolute quiet enjoined. Hot fomentations or hot poultices 
should be placed over the abdomen, and hot water injections 
should be used persistently. In puerperal cases, where septic 
poisoning is apparent and it is suspected that some parturient 
debris remains within the uterus, an intra-uterine injection of a weak 
solution of carbolic acid may be given. The rectum should be 
kept free by the use of enemata of warm water. In most cases, 
Aconite is the first remedy indicated, but usually Belladonna or 
some other remedy is soon required. According to my own ex- 
perience, after the initial symptoms calling for Aconite have disap- 
peared, Belladonna is indicated in a vast majority of cases, but the 
application of the remedy must in all instances depend entirely 
upon the individual symptoms of the case. 



176 A TEXT-BOOK OF GYNECOLOGY. 

Special Indications. 

Aconite. — Rigor; hard, full and rapid pulse; hot, dry skin; 
intense thirst; great restlessness and anxiety, with fear of death. 
Cases occurring from cold, during parturient period, or men- 
struation. 

Arsenicum. — Later stages; burning, lancinating pains; drinks 
often, but little at a time; great restlessness; typhoid symptoms. 

Belladonna. — Flushed face, throbbing carotids, bounding 
pulse, high temperature, active delirium, throbbing headache; 
drowsy, with startings, and inability to go to sleep; abdomen dis- 
tended and painful, very sensitive to touch; greatly aggravated by 
the least motion or jar of the bed; cutting pains, or clutching, as 
if the abdomen were clawed with the finger-nails; lochia sup- 
pressed. Most useful in puerperal metritis, but often indicated in 
non-puerperal. 

Bryonia. — The least motion aggravates her suffering; head 
aches as if it would split; sitting up causes nausea and fainting; 
lips and mouth parched; great thirst. 

Cantharis. — Scanty urine, with violent pains in the bladder; 
frequent urging and intolerable tenesmus; abdomen greatly dis- 
tended and tender, with violent burning or cutting pains. 

Also consult: Mercurius, Colocynthis, Pulsatilla, Rhus tox T 
Hepar sulph., Lachesis, Nux vomica and Sulphur. 



CHAPTER XX. 

CHRONIC METRITIS. SUBINVOLUTION. 

Synonyms. — Chronic parenchymatous metritis ; chronic in- 
flammation of the uterus ; chronic infarctus ; areolar hyperplasia ; 
diffuse proliferation of the connective tissue ; diffuse interstitial 
metritis. 

Definition. — The term chronic metritis is the one most often 
used to designate a morbid process in the parenchyma of the 
uterus, supposed to be inflammatory, which results in an increased 
growth of connective tissue. 

Pathology. — There is little uniformity of opinion as to the 
exact pathology of this condition. This fact accounts for the mul- 
tiplicity of names which it has received — names which have been 
based, supposedly, upon its pathology, which, at best, is obscure 
and not well understood. For this reason it is better to use the 
term chronic metritis; for while it may not be possible in most 
cases to trace an inflammatory origin, yet the ultimate tendency of 
inflammation in most structures is to cause an increase in growth 
of connective tissue, and that is the chief pathological change 
found in the disease under consideration, while, if we adopt a 
name based upon any one pathological state, we are liable to err, 
owing to our present incomplete knowledge of the subject. The 
term chronic metritis is the most appropriate one from a clinical 
standpoint, as it covers a variety of closely connected pathological 
states, which are possibly of widely different origin, but which 
present a similar class of symptoms and require similar treatment. 

For this reason I have included "Subinvolution of tne 
uterus " under this head, since that term expresses simply an etio- 
logical fact, that the increase in growth of connective tissue, which 
in no way differs from that resulting from inflammation, is the 
result of the failure of the uterus to return to its normal size and 
weight after parturition, the condition being "maintained by the 
process of chronic metritis, that is, by the formation of connective 
tissue, which takes the place of the fatty-degenerated muscular 
fibre." 

According to Thomas, who adopts the term ' ' areolar hyper- 
plasia," chronic metritis, however produced, is a vice of nutrition 
engendering hyperplasia of connective tissue as its most striking 
feature, and, although attended by many of the signs and symp- 



178 A TEXT-BOOK OF GYNECOLOGY. 

toms of inflammation, it in no way partakes of the character of 
that process. 

As to the pathological changes found in chronic metritis, 
there is, as I have already mentioned, much obscurity and some 
difference of opinion. The generally accepted views are embraced 
in a recent article by Dr. Palmer, (1) who recognizes three dis- 
tinct stages of chronic parenchymatous metritis : (1) Hyperemia ; 
(2) hyperplasia ; (3) sclerosis. The second is a result of the first, 
and the third is a practical continuance of the second. 

At first the uterus is enlarged, heavy, flabby, soft, and hyper- 
aemic. Later on, as a preponderance of the connective tissue re- 
sults through its proliferation, the organ is found dense and 
indurated ; at the same time it becomes less vascular. Diminished 
vascularity is brought about by the growth of the intermediate 
areolar tissue, especially surrounding the blood-vessels, compress- 
ing them and cutting off the current of their supply. This, the 
second stage of the disease, is called hyperplasia. Still later a 
further change becomes manifest, the result of the former. 
Advancing proliferation and hyperplasia of the connective tissue 
renders the parenchyma of the uterus more and more dense and 
indurated, less and less vascular, until finally a condition is found 
as described by Klob. The parenchyma on section appears white 
or whitish-red, deficient in blood-vessels, and its firmness is so 
increased by contraction and condensation that it creaks under the 
knife, simulating the hardness of cartilage. The uterus now 
grows smaller and undergoes atrophy. This is the stage of 
sclerosis or cirrhosis. 

Etiology. — According to Thomas, "as a very general rule 
chronic metritis is a consequence of subinvolution," all other 
causes becoming comparatively insignificant. He says: ''This 
constitutes the explanation of the fact that so large a number of 
women with uterine affections refer their illness to child-bearing, 
and that so many, who are well until that process, remain invalids 
afterward.. Go back to the commencement of all cases of uterine 
disease, and a very large proportion will date from parturition. " 

Subinvolution, then, being the chief etiological factor, it fol- 
lows that we should enumerate as causes of chronic metritis those 
conditions which interfere with the normal involution of the 
uterus. These are — 

1 . Contusions and lacerations of the cervix ; 

2. Retention of the products of conception, portions of the 
placenta, membranes or blood clots ; 

3. Pelvic inflammations after parturition ; 

4. Too early rising, after labor or abortion ; 

1) American System of Gynecology, Mann, p. 601. 






CHRONIC METRITIS. 179 

5. Non-lactation ; 

6. Repeated abortions. 

These causes all represent a source of irritation followed by 
congestion, and inducing persistent hyperemia. How this is 
brought about in the first three named, is evident. If the patient 
gets up too soon it leads to passive congestion, in an enlarged, 
flabby organ, and thus impedes involution. Non-lactation deprives 
the uterus of one of its normal stimuli to involution. This also 
holds good in abortions, where not only is lactation absent, but 
the patient does not take the same care of herself as after labor at 
full term. Moreover, after abortions conception often occurs again 
before involution is complete ; this favors another abortion and 
consequent subinvolution. Another class of causes are those 
which produce repeated or habitual congestions of the uterus. 
These are : Displacements, chronic endometritis, pressure of pel- 
vic or abdominal tumors ; chronic cardiac or hepatic disease ; excess- 
ive sexual indulgence, especially when under great excitement ; 
unsatisfied or abnormally satisfied sexual desire (masturbation or 
intercourse with impotent men, or withdrawing to prevent concep- 
tion, or the use of condoms and similar devices) ; prolonged con- 
stipation ; prolonged standing ; the wearing of tight or heavy 
clothing around the waist. 

Some of these, especially the first two named, might under 
some circumstances, be included under the group first named, as 
tending to retard normal involution after delivery. 

Symptoms. — The symptoms of chronic metritis may slowly 
succeed those of an acute attack, but in a great majority of cases 
they occur in a woman who has before been in good health, but 
who gets up from a confinement feeling poorly. Probably she has 
left her bed too soon, or allowed herself to work too hard soon 
after getting up. The first symptoms experienced are weakness 
and heaviness in the limbs, sacral and abdominal pains, mostly 
described as a backache and a feeling of weight or drao-o-mg in the 
pelvis ; the lochial discharge is increased and does not cease at the 
usual time, but merges into a leucorrhea, the extent of which de- 
pends largely upon the extent to which the endometrium is 
involved ; constipation is usually present and sometimes irregular 
hemorrhages occur. Several days before menstruation, and con- 
tinuing during that process, the patient may complain of a dull, 
heavy pain, and feel so weak and languid that she can scarcely 
leave her bed, and, not infrequently, especially if trying to go 
about, she is seized with paroxysms of faintness and hysterical 
attacks. Sometimes patients feel better after the flow, especially 
if it has been profuse, and in other cases they feel at their best 
at about the middle of the inter-menstrual period, the uterus being 



180 A TEXT-BOOK OF GYNECOLOGY. 

at that time free from congestion. The inter-menstrual symptoms, 
as a rule, are not intense, but only sufficiently severe to prevent 
the patient from enjoying perfect health, without being positively 
ill, while the monthly or still more frequent exacerbations, render 
her condition extremely distressing and intolerable. After a time 
there is pressure on the bladder and rectum, causing hemorrhages 
and violent rectal and vesical tenesmus. The digestion becomes 
more or less impaired, nutrition suffers, obstinate neuralgia and 
headaches occur frequently, the nervous disturbances become more 
numerous, and only slight influences are required to excite marked 
exacerbations. 

Often symptoms similar to those of pregnancy are present, 
such as nausea and vomiting, enlargement of the breasts, and dark- 
ening of the areolae about the nipple. 

All the symptoms are more marked when there is any marked 
displacement, and they are less severe when the disease is confined 
to the cervix and does not extend to the fundus. Pelvic inflam- 
mations not infrequently arise and render the condition more 
obscure and the treatment more complicated. Sterility is a fre- 
quent but not necessary consequence, but if conception does take 
place abortion is liable to occur about the fourth or fifth month. 

Physical examination reveals the uterus uniformly enlarged, 
and always sensitive, though not in a high degree, both the vol- 
ume of the uterus and its sensitiveness being markedly increased 
during an acute exacerbation. Sometimes the enlarged body may 
be felt lying retroflexed against the rectum, but if not it is usually 
readily felt through the abdominal walls by the bi-manual manipu- 
lation. During the first stage the organ is not firm, but rather 
soft and doughy, while in the second stage it becomes more hard 
and dense. In cases of long standing the cervix is hard, and often 
quite irregular, presenting somewhat the appearance of carcinoma. 
The os is patulous and the lips thick, often presenting erosions con- 
sequent upon endometric complications. 

Diagnosis. — Chronic metritis may be mistaken for pregnancy, 
as the conditions present so many symptoms in common, but in the 
former, menstruation, though irregular, rarely ceases altogether, 
and the uterus is distinctly sensitive to touch, which is not the case 
in pregnancy. Should conception occur in the course of chronic 
metritis, the diagnosis is exceptionally difficult. Interstitial and 
submucous fibroids may give trouble in diagnosis, and it may be- 
come necessary to dilate the cervix, in order to ascertain by digital 
examination whether or not the enlargement is confined to but one 
wall of the uterus ; but usually the history of the case and the 
sensitiveness of the uterus will establish the presence of an inflam- 
matory process, though a fibroid may be found to co-exist. 






CHRONIC METRITIS. 181 

Prognosis. — The life of the patient is not directly endangered, 
but the chances of complete recovery are, in most cases, quite lim- 
ited. Often the disease will last for years, periods of tolerable 
health alternating with those of violent distress and suffering. 
Very rarely does the disease terminate before the menopause, 
though in some cases the third stage, that of induration, sets in 
earlier, the exacerbations disappear, and the patient feels compara- 
tively well. Frequently the patient's sufferings are largely due to 
the complications that exist rather than to the original disease. 
Those cases which result from displacements are more amenable to 
treatment, the removal of the exciting cause producing rapid and 
permanent recovery. The disease is unquestionably one which 
obstinately resists treatment, and the prognosis of a complete re- 
covery before the menopause quite unfavorable, yet much may be 
done to diminish the patient's sufferings, and where she can be 
brought to rigidly observe hygienic rules, avoid exposure, undue 
exercise during the menstrual period, abstain from frequent sex- 
ual indulgence, and be fortunate enough to escape conception and 
consequent abortion, I am convinced that homeopathic remedies con- 
joined with appropriate auxiliary treatment will, in many instances, 
effect a cure, though of course it is not to be understood that a 
restitutio in integrum is probable, or that the tendency to relapse 
can be entirely overcome. 

Treatment. — Prophylactic measures are of great importance. 
Subinvolution is often the result of improper care during the 
puerperium. The patient should not be allowed to leave her bed 
too soon, or to devote herself to household cares until involution 
is completed. Any obvious causes, such as endometritis, lacerated 
cervix, or displacements, should receive immediate attention. 
During the menstrual period, and at other times when exacerba- 
tions are present, the patient should keep her bed, and absolute 
rest should be enjoined. At other times she may continue her 
usual household duties, being careful to avoid all active exertion, 
especially such as is most likely to bring about contraction of the 
abdominal muscles or jar of the pelvic viscera — hard labor, rough 
riding, jumping, lifting, etc. Gentle exercise on foot in the open 
air and sunshine is very desirable, but should never be carried to 
the point of actual fatigue. It is a mistake to allow a woman with 
this disease to remain continually in bed, as such a course would 
interfere with the processes of nutrition and result in positive in- 
jury. The diet should be simple and nourishing, the coarser foods 
which tend to increase the quantity of fecal matter being avoided, 
preference being had for an animal and fruit diet. The bowels 
should be kept regular, not only by appropriate diet, but also by 
enforced regularity in evacuations, and, if . necessary, the use of 



182 A TEXT-BOOK OF GYNECOLOGY. 

appropriate mineral waters, but cathartic medicines should never 
be employed. Physical rest of the uterus, as far as the sexual 
relations are concerned, should be advised, though no doubt in those 
women in whom there is strong sexual desire, a moderate indulgence 
is preferable to absolute abstinence. 

Hot water vaginal injections should be used every evening 
before retiring. 

The local treatment of chronic metritis is very unsatisfactory, 
and benefit must be expected mostly from the measures already 
mentioned and the use of the appropriate internal remedies. Local 
depletions, scarifications, blisters, cauterizations, etc., are, to my 
mind, not only useless, but in many cases positively harmful, and 
not to be thought of. This statement does not include Dr. 
Apostolus new method of treatment by intra-uterine chemical 
galvano-cauterizations, which is described in a subsequent chapter, 
and which promises to become a valuable addition to gynecological 
therapeutics. (See Chapter XXI.) I have had several patients 
who obtained prompt temporary relief, at least, from the daily 
application of the glycerine plug. In some instances I have 
applied with benefit a solution of equal parts of iodine and 
glycerine to the cervix and vaginal roofs. 

S. Wier Mitchell's method of treatment by rest, feeding, mas- 
sage and electricity, has given good results in chronic metritis, and 
is highly spoken of by Playfair and other distinguished gynecolo- 
gists. It has the advantage of doing away with the objectionable 
methods of treatment usually adopted by the old school, and 
recommends itself at once as practical and efficient, especially in 
those cases where the nutrition has suffered and the nervous sys- 
tem has become depressed and weakened, as shown by emacia- 
tion, digestive derangements, and nervous debility. It consists 
chiefly in — 

1. Removing the patient from her old surroundings; 

2. Absolute rest in bed; 

3. Treatment without narcotics or cathartics; 

4. A systematic diet, consisting chiefly of large quantities 
of meat, eggs and milk; 

5. The energetic use of massage to strengthen the muscles 
and increase their activity; 

6. The application of the Faradic current daily, to cause 
muscular action and act as a tonic. 

In regard to this method of treatment, Dr. Winckel says (1): 
" I have treated many patients by this plan, and can assure the 
reader that the results are very favorable. It does not always 



1) Diseases of Women, Parvin, p. 462. 



CHRONIC METRITIS. 183 

render local treatment superfluous, but it has a happy effect so far 
as constipation is concerned, and with the restored circulation the 
uterus often perceptibly diminishes in size; the secretions are like- 
wise profuse, and local treatment is not so essential as formerly. 
The patient finally has a suitable diet substituted for the host of 
medicines, the hysterical symptoms gradually disappear, the cold 
hands and feet grow warm, and her former blank existence de- 
velops new life." 

Therapeutics. 

The subjective symptoms of chronic metritis, associated, as 
the disease usually is, with so many varied complications, are so 
protean that its therapeutics can only be established by a study of 
each individual case on its own merits, and a remedy selected to 
cover the totality of the symptoms presented. At the time of the 
acute exacerbations, the case may demand Belladonna, Gelsemium, 
Cimicifuga, Pulsatilla, Viburnum op., Seiiecio, Sabina. The reme- 
dies most often useful in the course of the disease are Arsenicum, 
Arsenic iod., Aurum, Calcarea carb., Conium, Ferrum, Ignatia, 
Iodium, Kali iod., Phosphorus, Lachcsis, Lilium tig., Lycopodium, 
Mercurius iod., Natrum mm*., Nux vomica, Phytolacca, Pulsatilla, 
Platinum, Sepia, Sulphur, Ustilago maidis. 

Arsenicum. — Burning or lancinating pains in the uterine 
region; great restlessness and anxiety; pains in region of right 
ovary, sometimes extending into the thigh, which feels lame; great 
weakness and prostration; pale, cachectic look. 

Arsenicum Iod. — This remedy is more useful where, with 
the above symptoms, the uterus is considerably enlarged and 
indurated. 

Belladonna. — More useful in acute metritis, and during the 
acute exacerbations of the chronic variety. Abdomen distended 
and sensitive to touch, or jarring; heat, throbbing, burning and 
weight in uterine region, with pressure downward; attacks of 
colic, as if the uterus were seized with the finger-nails; throbbing 
headache, flushed face, even delirium; monorrhagia, blood red 
and hot. 

Calcarea Carb. — Strumous diathesis; leucophlegmatic tem- 
perament; menses too early, too long and too profuse; leucorrhea 
like milk; abdomen distended and hard; profuse sweat from 
slightest exertion; feet cold and damp; acidity of the stomach; 
feels Avorse after coition. If with these symptoms the uterus is 
enlarged and greatly indurated, Calcarea iodatum is the better 
remedy. 

Conium. — Induration of the uterus; lancinating pains; sore- 
ness and swelling of the breasts preceding menses; milky, acrid 
leucorrhea. 



184 ' A TEXT-BOOK OF GYNECOLOGY. 

Cimicifuga. — In nervous, hysterical women; menses irregular 
or suppressed; pains in uterine region shoot from side to side; 
bearing down in uterine region and small of back; limbs feel 
heavy and torpid; severe reflex pains in head and eyeballs. 

Gelsemium. — Symptoms always worse during the menses; 
severe, sharp, labor-like pains in the uterine region, extend- 
ing to back and hips; trembling and weakness; relaxation and 
prostration of the whole muscular system; languor; aching in the 
limbs. 

Ignatia. — Hysterical ; frequent sighing ; gloomy, seems 
weighed down by imaginary grief and sorrow; sensation of weak- 
ness and sinking in pit of stomach; menstrual blood black, clotted 
and of putrid odor. 

Iodium. — Induration of the uterus; metrorrhagia, renewed 
after every stool; acrid leucorrhea, mammae dwindle away and 
become flabby; sallow complexion; local or general emaciation, 
especially in scrofulous women. 

Kali Iodatum. —Especially in mercurial or syphilitic sub- 
jects; tendency to ozrena and to diseases of the bones and glands; 
always worse at night. 

Lachesis. — Abdomen distended, hot, sensitive and painful; 
pains like a knife thrust in uterus, relieved by a flow of blood; 
uterus will not bear contact even of bed clothes, which cause 
uneasiness; metrorrhagia, blood black; great exhaustion; worse 
after sleep. 

Lilium Tig. — Subinvolution; displacements; bearing down, 
with sensation of heavy weight and pressure in uterine region; 
sharp pains in ovarian region; reflex heart symptoms; great 
depression of spirits. 

Pulsatilla. — Heavy pressive pain in abdomen and small of 
back, especially during menses; menses suppressed or delayed 
from getting the feet wet; leucorrhea like cream or milk; charac- 
teristic temperament; symptoms ever changing; dyspepsia; always 
better in the open air. 

Sabina. — Subinvolution after abortion; hemorrhage from 
the uterus in paroxysms, worse from motion; blood dark and 
clotted; pain from back to pubes. 

Secale. — Subinvolution; abdomen distended and tympanitic; 
uterine hemorrhage, worse from least motion; discharge black, 
fluid and very fetid; suppressed lochia followed by metritis; 
extreme debility, prostration and restlessness. 

Sepia. — Venous congestion of the uterus and adjacent tissues; 
abdomen distended and sensitive; sensation of bearing down, feels 
that she must cross the limbs to prevent protrusion of the parts; 



CHRONIC METRITIS. 185 

prolapsus uteri; leucorrhea, yellow like milk, excoriating, worse 
before the menses; easily fatigued; sensitive to cold air; face pale, 
yellow earthy color; yellow saddle across the nose. 

Sulphur. — Most useful as an intercurrent remedy in long- 
standing cases occurring in scrofulous subjects. 



CHAPTER XXL 

TREATMENT OF CHRONIC METRITIS, ENDOMETRITIS AND PERI- 
UTERINE INFLAMMATION BY ELECTRICITY. 

The attention of the profession has lately been attracted to 
the value of electricity in the treatment of pelvic inflammations by 
Dr. Apostoli, of Paris, whose monograph (1) has recently been 
translated and published in this country, and who has still more 
recently furnished a paper on " A New Treatment by Electricity 
of Peri-uterine Inflammation." (2) 

The method of treatment practiced by Dr. Apostoli is wholly 
original Avith himself, and is concisely set forth in the monograph 
and paper above mentioned, from which I shall quote, and to 
which the reader is referred for more extensive information. In 
the first place, Dr. Apostoli very properly remarks that "notwith- 
standing the variety of names which have been given to peri- 
uterine inflammations, sometimes fashioned only according to the 
inventive ingenuity of authors, and sometimes only indicating the 
localization, they all mean pretty much the same thing, except as 
regards the point of intensity. 

"Whether it be called a peritonitis, a parametritis, a phleg- 
mon, or a cellulitis, we have always to deal with a peri-uterine 
inflammation, either limited to the cellular tissue only, or involv- 
ing all that is. included in the pelvic folds of the peritoneum. 
Throughout, the therapeutical indications are much the same, and 
it is of them only I wish to speak." 

His treatment is, therefore, practically the same in all forms 
of pelvic inflammation, according to the stages of the disease — 
acute, sub-acute or chronic. 

In his monograph, Dr. Apostoli first explains the five instru- 
ments which are required: 

1. "Above all, a good Galvanometer." — The reasons 
are given at length why this requirement is of the utmost import- 
ance. The Galvanometer shows the passage of the current and 
its slightest variations of intensity, and gives the exact measure of 
electric outflow — "it doses and weighs, so to speak, the electric 
current." No correct idea can be had of the quantity of electric 

1) On a New Treatment of Chronic Metritis, and Especially of Endometritis, with Intra-uterine 

Chemical Galvano-Cauterizations. Detroit: George S. Davis. 1888. 

2) British Medical Journal. See Medical Era, April, 1888, p. 114. 

18G 



CHRONIC METRITIS. 187 

current by simply estimating the number of cells employed, as 
these invariably differ in their output, and the same cell may 
differ at different times, according as it is fresh or worn out, and 
from other circumstances. 

2. The Battery. — Here Dr. Apostoli recommends the 
Leclanche cell, but any other one will answer. The object is to 
select a battery " which gives the least trouble, and which, while 
giving a great outflow, lasts the longest possible time without 
having to be recharged." He advises using large cells. An 
average of about twenty large Leclanche elements is required to 
furnish the intensity — from 150 to 250 milliamperes — necessary 
for the operation. For a portable battery none has yet been de- 
vised that fully answers the purpose, but the bisulphate of mercury 
battery comes nearest to the requirements. 

3. Intra-Uterine Exciter. — This consists of a platinum 
sound "held by a long handle, into the centre of which it should 
glide. It must be about ten centimeters in length, furnished with 
a sheath, and made of some good non-conductor, so as to protect 
the sensitive vagina from contact with the electrode; it may be 
made of glass or rubber, but the best material is celluloid. Its 
diameter should be such that it will slide easily over the sound, 
so as to expose as little or much of the latter as the operator may 
desire." 

An ordinary metallic sound would answer, were it not that the 
positive pole would cause it to become corroded. Dr. Stevenson 
uses a copper wire, insulated by gum elastic, to the end of which 
is welded a piece of platinum of about an inch in length. This 
makes a more flexible instrument, is less expensive, and is probably 
equally as useful as that recommended by Dr. Apostoli. 

4. Cutaneous Electrode of Clay. — This new electrode, 
designed by Dr. Apostoli, renders the cutaneous pole innocuous, 
and thus the current is made tolerable to the patient in spite of 
the enormity of the dose. It consists of a piece of good plastic 
clay about ten inches by five, placed upon the abdominal parietes, 
in which is embedded a flat metal plate, about five inches by three, 
to which one of the rheophores is attached. 

5. The Rheophores. — These arc the cords "which serve to 
carry the current, the one from the battery to the uterine sound, 
and the other from the battery to the clay. These cords are 
generally formed of several metallic wires, placed together and 
covered with silk or rubber, and should be sufficiently resisting, 
on the other hand, not to be easily broken. It is their breaking, 
in fact, which is the most common accident, and generally hap- 
pens when least expected, and against which I must put you on 
your guard." 



188 A TEXT BOOK OF GYNECOLOGY. 

Before detailing Dr. Apostolus method of procedure in chronic 
inflammations, I will first quote his general lines of treatment for 
the acute and sub-acute stages of peri-uterine inflammation. 

1. Acute Stage. — Dr. Apostoli Faradizes every woman, 
even when under an acute attack of inflammation, observing, how- 
ever, the following practical conditions: 

u (a) I proscribe every Faradization that would cause the 
least pain, and expressly that of quantity, engendered by the 
bobbin with short and thick wire, (h) I use for such cases the 
bobbin with long and thin wire, from which I obtain a current of 
tension, on account of its specially anodyne effects, (c) I begin 
with a simple vaginal application, by means of a large bipolar 
electrode, the point of which is placed against the inflamed part. 
(d) I only employ a current easily bearable, so as to cause no 
suffering or any excitement of the patient, as this would insure an 
entire failure of the treatment, (e) All the success of this medi- 
cation depends upon making the first sittings sedative, so that 
they may serve as a prelude to more active measures; and the 
Faradization will only become hyposthenic on the double condition 
of its low intensity and its long duration, (f) Each sitting should 
last five, ten, fifteen, twenty or twenty-five minutes, as may be re- 
quired, and should not terminate before the patient spontaneously 
declares that she is better and suffers less, (g) It is necessary to 
reinforce what has been said, by dogmatically averring that no 
success will come out of this treatment unless it is managed, not 
only without violence, but with extreme gentleness, (h) There 
may be one or two sittings each day, as may be wanted, for lower- 
ing the febrile action, allaying pain, and bringing about what is 
called the sub-acute state of the inflammation, (i) Every Farad- 
ization should be preceded and followed by a vaginal irrigation 
with the sublimate solution, and all the sounds should be scrupu- 
lously disinfected. 

" 2. Sub-acute Stage. — As soon as the sound can be intro- 
duced into the uterus without much pain and without danger, I 
consider this stage to have set in, and it requires some alteration in 
the treatment. Intra-uterine medication is now necessary, its force 
being increased gradually. It is here that we can advantageously 
combine Faradizations with the continuous current. 

"a. I recommend, first, bi-utcrine Faradization, because 
we desire to prolong in the uterus the same anodyne effects that we 
sought for in the vagina. We' must, therefore, Faradize the 
uterine cavity. 

"The current must always be that of tension. The intensity 
is increased by advancing the bobbin, and this must be done as 
softly as possible, without any jerking, till we reach the limits of 



CHRONIC METRITIS. 189 

personal tolerance. Every day the current may be repeated, until 
an evident amendment is taking place and the inflammation is giv- 
ing way. This will be the indication for still more decided action 
and we must call to our aid the constant galvanic current. 

"b. The use of the intrauterine galvanic current, in small 
but gradually increasing doses, is the second part of the treatment 
which we have to offer to the patient, with a view to more rapid 
progress in the cure. Here the action is purely chemical, dynamic, 
and stimulant, and intended to stop any tendency to suppuration, 
and to accelerate the absorption of the morbid deposits. 

44 We must begin with short sittings of only three or four 
minutes, with an intensity of not more than twenty to forty 
milliamperes. After a while, both doses and time may be aug- 
mented, and we have no better guide to trust than the case with 
which the patient can support this intra-utcrine cauterization. The 
most exact care must be taken not to transgress any of the rules I 
have laid down for the safe performance of the operation, never 
omitting the diligent observance of every antiseptic precaution. 

44 One or two sittings a week may be made, regulating the 
intervals by the strength and condition of the patient. Rest in 
bed after each operation must be enforced. 

14 The early cauterizations should be with the positive pole, as 
it occasions less congestion than the negative. The negative 
cauterizations, having a greater derivative power, must, however, 
be brought to bear as soon as we can make out, by the way in 
which the action of the positive pole is tolerated, that they can be 
aptly and beneficially employed. 

44 The surgeon must never lose sight of the fact that, with his 
patient on the confines of an acute stage of disease, he is handling 
a curative agent which, while capable of rendering great service, 
may also, by indiscreet and inexperienced usage, do her grcvious 
mischief. 

44 To sum up this part of the subject: these two stages of 
acute and sub-acute perimetritis are difficult to overcome, and our 
great effort must be to get rid of them, and to place the patient in 
that chronic stage in which our action will be more clear and 
definite. 

4 4 3. Cheonic Stage. — However excusable a certain amount of 
timidity and indecision may be in treating the acute and sub-acute 
conditions of this disease, there is nothing to hold back the surgeon 
from following my recommendation to act boldly, and even heroi- 
cally, when he comes to encounter the chronic stage. Here he 
must, judiciously but unhesitatingly, push the intra-uterine gal- 
vano-cauterization to its highest pitch, and then superpose the 
vaginal chemical galvano-punctures, negative and monopolar." 



190 A TEXT-BOOK OF GYNECOLOGY. 

A short summary of the rules for manipulating in the opera- 
tion of galvano-puncture may be found in the chapter on u The 
Treatment of Fibroids by Electricity.'" 

It now remains only to give a brief summary of the method 
of conducting chemical galvano-cauterizations. 

A— Preparatory Precautions. 

1. Dr. Apostoli insists on carrying out "a good and 
thorough antisepsis." 

2. "Examine all the couples of the battery, in order to see 
that they work well, and thus to avoid any interruption during the 
course of the sitting." 

The elements should be turned on cup by cup, so as not to 
cause too sharp and sudden a transition, thus preventing violent 
shocks to the patient. "There is always a slight shock, it is true, 
but it is reduced to a minimum. If, on the contrary, the collector 
is divided two by two, three by three, or even four by four, the 
shock becomes greater with this transition, and the patient finds 
herself in the position of one who ascends or descends easily a 
flight of stairs, step by step, but who, when she goes up two or 
three steps at a time, finds it much more difficult." 

3. Examine the galvanometer and "make sure that the 
needle oscillates in every direction without striking, and that it is 
perfectly suspended." 

4. " The battery, collector and galvanometer having been 
tested, we place them near the operating bed or sofa, so that, with- 
out moving, you can on one side stretch out the hand and easily 
move the handles of the collector, and on the other hand be able 
to see and follow easily during the whole operation the oscillations 
of the galvanometer. You adjust the needle, or, rather, you turn 
the multiplying scale until the zero on the compass corresponds 
exactly with the needle." 

5. "Pass the hysterometer through the flame and then you 
plunge it, handle and all, into a strong carbolic solution, in order 
to make sure of its being perfectly a septic. 

"Arrange the length of the intra-uterinc sound, in drawing it 
out from the handle, according to the previously determined or 
the probable length of the uterus. Then cover the sound with an 
insulating sheath of celluloid. 

6. "Attach the rheophores, or, better still, one rheophore 
first, to the metallic plate which lies upon the clay. 

7. " See if the clay is in the proper condition for humidity, 
and especially if it thoroughly moistens the tarlatan." 

B — Preliminaries. 

1. Explain to the patient that the operation is harmless and 



CHRONIC METRITIS. 191 

perfectly bearable. It "is necessary never to begin, especially the 
first time, before obtaining her complete aquiescence, in order that 
she may relax all her muscles and avoid all movements that might 
be hurtful or dangerous."" She must remove her corsets and 
loosen her skirts, in order that her breathing may be free and 
easy, and that the abdomen may be completely exposed. The 
operation may be performed at the office on an ordinary operating 
table. If at the patient's house, she should lie across a bed, "the 
feet resting on two chairs, taking good care, however, in both 
cases, that the buttocks project completely beyond the edge, in 
order to give perfect freedom to the hand which introduces and 
holds the mtra-utcrine sound. 

"Once placed in position, the woman must remain absolutely 
immovable, and you must remind her that, no matter what hap- 
pens, she must not move, but that on the slightest sign, if she de- 
sires, you will stop the operation; she will thus be more satisfied, 
she will breathe easier, and will aid any manoeuvre required for 
the introduction of the sound. 11 

2. "Quickly place the clay on the belly, above the pubis, 
and away from the hairs, after having warned the patient that it 
is always cold, but that this disagreeable feeling will soon disap- 
pear. Cover it with a dry cloth, such as a folded towel, for 
instance, on which the woman is to place her two open hands side 
by side, so. that she may exercise a slight pressure on the clay, in 
order to render it more uniformly and completely applied to the 
skin. 

"Never apply the clay to the skin without having first deter- 
mined that the epidermis is healthy, and that there are no pimples 
or abrasions, nor any wounds of any kind, no matter how small." 

3. The sound is now introduced. "This is the most im- 
portant stage, and exacts the greatest care and practice. A great 
part of the operative success depends on its good execution." It 
should be handled with extreme gentleness, and only the slightest 
possible force used; on the slightest resistance the sound should 
be withdrawn, and another attempt made. Dr. Apostoli rejects 
the use of the speculum entirely. The left hand holds and fixes 
the handle, at the same time giving it a slight forward movement; 
"the other hand, with the index finger in the vagina and adjacent 
to the posterior lip, following it, and guiding it, when necessary, 
in all its movements laterally and forward, straightening and cor- 
recting its course when it goes wrong." 

4. " Once the sound is well introduced into the whole extent 
of the uterus, you must take care that the vagina is well protected 
by the isolating covering of celluloid, and for that, it ought to 
touch at one end of the neck of the uterus and at the other project 



192 A TEXT-BOOK OF GYNECOLOGY. 

from the vulva. During the operation, we should not cease to be 
careful of this, for if it should become all at once and suddenly 
painful, you will generally find that it is for want of watching the 
handle, which has slid forward, and which no longer protects the 
vagina in its entirety.'" 

5. " Attach the rheophorc to the intra-uterine exciter, taking 
care to do so sufficiently firmly that it may not become detached 
during the seance, and thus cause a shock, which would result 
from the interruption of the current." 

C— The Operation. 

This is divided by Dr. Apostoli into three stages, the initial 
stage, the middle stage, and the end. 
1. The initial stage. 

(A) "You must not begin to turn on the current until all 
pain or sensibility resulting from the passage of the sound shall 
have disappeared. A few seconds of waiting are sometimes 
necessary for this purpose. 

(B) " This done, the hand which holds the sound steady will 
move no more ; in order to give it more security it is better to leave 
the conducting finger in the vagina, where, if we are sufficiently 
sure of ourselves, we hold the sound by the handle ; the dorsal 
surface of the handle will rest against the internal surface of the 
corresponding thigh of the patient. 

(C) " You will now turn your eye toward the compass to 
see how it answers to the passage of the current, and at the same 
time you must not lose from your sight the countenance of the 
patient, which will warn you of all the sensations she feels. 

(D) "The hand which remains free should be placed on that 
handle of the collector which corresponds to the positive pole, as 
the operator desires it ; for the characteristic of the positive pole 
is that it always belongs to the handle which is in motion or which 
is at the highest figure, while the handle which remains stationary, 
or is at zero, or at a figure lower than that of the handle which 
moves, belongs to the negative pole, according to the method of 
construction of Gaifi'e. 

(E) "You will then commence slowly, very slowly, to turn 
on the cells, especially if it is the first operation you have under- 
taken, or if you arc not acquainted with the patient. At first you 
will go to twenty or thirty milli amperes. Then proceed to fifty. 
By this time you will have gained, what it is very important to 
do, the confidence of the patient, who will soon find out of her 
own accord that electricity docs not cause much pain. You will 
then reach seventy, eighty or a hundred milliampcres, and it is 
better for the first time not to go beyond this figure. 



CHRONIC METRITIS. 193 

(F) "It is therefore important never to make the patient 
suffer too much and never to inflict more pain than is bearable. 
This is the true criterion which should fix the limit of the dose." 

2. The middle stage. 

(A) "Generally a few seconds suffice to apply to the uterus 
in an ordinary operation the maximum dose desired, but with very 
nervous or very hysterical women, and especially when we operate 
for the first time, avc must take care to wait one or, if necessary, 
two minutes, to arrive at the maximum dose which they can bear. 

(B) " The point that we can reach will generally be 100 
milliamperes at the first sitting ; during the others we may try to 
raise it to 150 and even 200. We can, if necessary, when a 
serious case requires it, reach 250. The maximum figure once 
obtained, which differs, I repeat, according to the patient, we will 
keep at the same level during a period of between five and ten 
minutes, but on an average of five minutes. 

(C) ' ' The variations that should take place in the dose and the 
duration of the operation, arc justified by this fact, namely : That 
in the first place all women do not support electricity equally well, 
and besides they each require a different intensity according to the 
gravity and previous duration of the disease ; thus it is advisable 
in a difficult case of severe hemorrhage with marked fungous endo- 
metritis, to prolong the application to the maximum possible point 
of toleration, which might he as much as ten minutes ; with other 
persons, on the contrary, very hysterical and nervous, and easily 
enervated by the slightest pain, a sitting of three or four minutes 
will be as much as they can bear. 

(D) "There is an important precaution which you must 
take during the sitting, and which concerns the method of hold- 
ing the sound ; it is necessary to hold all the intra-uterine portion 
always applied against the uterine wall and as far as possible to put 
it successively in contact with each of them, anterior, posterior 
and lateral, in order to disseminate and equalize in this manner its 
caustic action, and to render it as efficacious as possible. 

(E) "One thing it is important to know, and this is to under- 
stand the oscillations which take place in the needle during this 
period, while the number of cells in use remains the same. 

"In certain patients, who have a very resisting skin, we must 
not be surprised to see the deviation of the needle become greater, 
which bears witness to the increasing electric intensity or outflow, 
which increases because the current passes through the epidermis, 
which has taken a certain time to become softened and to allow 
itself to be penetrated. Once having reached the summit of its 
course, the needle generally becomes stationary, or moves at least 
but slightly, and thus proves by its greater or less fixation, that the 



194 A TEXT-BOOK OF GYNECOLOGY. 

current once having been well established circulates in an almost 
continuous and identical manner." 
3. TJie End. 

(A) "The same precautions, which I have just advised 
for the application of the current, should be always rigorously 
applied in order to suspend it. You must stop gradually couple 
by couple, and never suddenly, in order to avoid shock and pain- 
ful contraction of the uterus or abdominal wall which would 
follow. 

(B) "When must you finish the sitting? I have just said 
that two factors should enter into serious consideration. The ob- 
ject to be obtained and the sensibility of the subject. 

' ' If the woman tolerates it well, and bears the current with- 
out complaining, the duration, according to the therapeutical object 
in view, should be from five to eight minutes, and even ten minutes. 
If she does not tolerate it, but complains loudly, threatens to move 
and becomes agitated, you must know that you should stop. 
There is every reason to believe that the next sitting will be better 
borne, either because the motion of the first beginning will be less, 
or because the uterus itself will not be so irritable. 

(C) "If the same intolerance were manifested at the fol- 
lowing sitting, you would have reason to suspect a peri-uterine 
cellulitis, which had been overlooked and in the presence of which 
you must stop, or it may be an extraordinary uterine susceptibil- 
ity, as I have seen in certain cases of hysteria, rare, it is true, 
which have compelled me to stop my interference at a dose of 
thirty or fifty milliamperes. ,, 

(D) Here Dr. Apostoli explains why it is that* when the 
handle of the collector has been brought back to zero, the needle of 
the galvanometer passes a little beyond zero, showing a slight cur- 
rent, but sufficient for the patient to recognize, so that she may 
ask : "Are you beginning again?" 

(E) The sound is then very carefully and slowly withdrawn, 
after which the clay which adheres to the abdomen is removed. 

(F) "You then wash out the vagina again with the same 
antiseptic solution, and you leave in there a tampon of iodoform 
gauze, the use of which has a double object ; first, to continue the 
antiseptic during the interval between the sittings, and secondly, 
to put a certain amount of impediment in the way of coition, 
which is very important. " 

D — After the Operation. 
"The instructions which you should give to the patient who 
has just been treated are of the very greatest importance, for on 
their being well executed the whole success of the operation 
depends. 



CHE ONIC ME TBITIS. 195 

(A) ' ' If we desire that the treatment should bear its full 
fruits it is absolutely necessary that the patient should lie down at 
full length during a time varying from one to several hours. 

"If the operation has been performed in the doctor's office, 
the patient should only go home as late as possible after the colics 
which follow the cauterization shall have partly disappeared. She 
should avoid all fatigue and rapid movements, and you must repeat 
to her that the forgetting of these instructions may expose her to 
a serious inflammation (such as perimetritis) with all its accompany- 

niseries. 

(B) "You should always warn the patient of the uterine 
colics, which are generally in proportion to the intensity of the 
operation which she has undergone. Frequently the post-opera- 
tive period is even more painful than the operation itself. The 
woman should not be subjected to any surprises ; and therefore it is 
better to tell her beforehand what she may expect. 

(C) "You will tell her that a sanguineous discharge may 
appear in the course of the evening as a result of what she has 
just gone through, a discharge which is not severe and which is 
generally stopped of its own accord, by rest, without any treat- 
ment. 

(D) " The following days she may also have a sero-purulent 
discharge which depends upon the same cause, and which only re- 
quires antiseptic vaginal injections every night and morning. 

(E) "You must formally forbid all sexual intercourse that 
night and the following one ; it would be even good to suspend all 
conjugal relations during the whole course of the treatment in order 
to avoid pregnancy, which, if it came on prior to the operation, 
might result in an almost fatal abortion. 

(F) "All the discomforts whatsoever, which may be felt, are 
generally tolerable, and rest is, without exception, the best way of 
diminishing them ; they disappear of themselves the same evening, 
or, perhaps, the following day. In cases, however, where the pain 
is too great, you may order the application of a large emollient 
poultice on the belly, which will diminish to a certain extent the 
pain following the application." 

As regards the number of sittings required Dr. Apostoli says : 
' ' In one case, fresh and easily curable, from three to five sittings 
will be sufficient, 

"In another, older and more rebellious, ten to fifteen will be 
necessary. 

"A third, exceptionally, may require twenty to thirty appli- 
cations. 

tk It is the old, chronic, indurated form of metritis with slow 
and perverted circulation which especially demands a long, labori- 



196 A TEXT-BOOK OF GYNECOLOGY. 

ons treatment. A chronic disease requires a chronic treatment, and 
we will be only too happy to see, in a disease reputed incurable, 
our efforts often (I do not say always) crowned with success. 

' ' The treatment should not stop until, on the one hand, all 
hemorrhage, pain and other disorders have ceased, and the patient 
declares herself symptomatically cured ; menstruation will have 
gained its regular and easy rhythm ; walking will be easy ; all the 
functions will be well performed. On the other hand, we must 
obtain the anatomical confirmation of this clinical condition of 
which the patient is the best judge ; we must by touch, aided by 
the other means of exploration, establish the disappearance, or at 
least the diminution, of all previous disorders ; for if the disease is 
symptomatically curable, we must sometimes declare ourselves 
satisfied with only a partial anatomical retrogression ; if any dis- 
placing of the uterus, if any light pressure on the uterine walls 
does not awaken any appreciable sensibility, there is every chance 
that the organ is well and that the woman is cured." 

It is best to ''complete the cure by several supplementary 
sittings, destined to bring it to a close and to give it a condition of 
stability." 

It should also be mentioned that Dr. Apostoli treats those 
cases where there is actual or threatened suppuration, by using the 
negative galvano-puncture, forming an eschar, opening up a sinus, 
and directing the exit of the pus to the nearest point of the 
vagina, which he says ' ' we can do at will, when it is most fit to do 
it, and in the most convenient way. 

"We have, then, in all the galvano-puncture, an effective 
means of arresting an inflammation, and of dispersing an inflam- 
matory deposit. Or, we may use it as a sure and direct way of 
opening a profound and ready formed collection of pus. No plan 
of setting up a vaginal drainage, controllable as to amount and 
duration, can be more simple ; and this we may associate with any 
local and antiseptic treatment that may be desirable." 

There are, of course, many points of interest connected with 
this new and valuable addition to gynecological therapeutics which 
cannot be mentioned within the limits of a general treatise, for 
which the reader is referred to Dr. Apostolus publications. 



CHAPTER XXII. 



DISPLACEMENTS OF THE UTERUS. 

Definition. — This comprehends any persistent or permanent 
change in the location or position of the uterus. Transient dis- 
placements, resulting from such causes as violent straining, cough- 
ing, or an over-tilled bladder, are physiological, but when the 
organ fails to return to its normal position after such physiological 
migrations, or after dislocation resulting from any cause, then the 
condition is pathological and constitutes a displacement. In order 
to understand the causes and pathology of displacements of the 
uterus, a previous knowledge of the anatomy and physiology of 
the uterus and its supports is essential, for which the reader is 
referred to Chapter I. 

Varieties. — The various forms of displacement are known 
as (1) Ascent, the uterus being dragged upward; (2) Descent, or 
Prolapsus, the uterus being depressed downward; (3) Anteversion, 
tilted forward; (4) Retroversion, tilted backward; (5) Latero- 
version, tilted laterally; (6) Anteflexion, bent on itself forward; 
(7) Retroflexion, bent on itself backward; (8) Lateroflexion, bent 
on itself laterally; (9) Inversion, the uterus being turned inside out. 

Etiology. — Displacements may, in general, be produced by — 

1. Any cause increasing the weight of the uterus; 

2. Any cause weakening the supports of the uterus; 

3. Any cause producing undue pressure from above; 

4. Any cause producing undue traction from below. 

1. Causes increasing the weight of the Uterus. — 
Congestion; chronic metritis ; subinvolution ; tumors of the 
uterus ; pregnancy. 

2. Causes weakening the supports of the Uterus. — 
Ruptured perineum; destruction of the pelvic fascia; relaxed 
vagina; stretching of the uterine ligaments; lack of tone in uterus 
or appendages; absorption of pelvic fat and connective tissue. 

3. Causes producing undue pressure from above. — 
Great muscular efforts; tight clothing, or heavy clothing sup- 
ported from the waist; abdominal growths or exudations; accumu- 
lations of feces or urine; straining at stool; severe chronic cough; 
sudden heavy fall. 

4. Causes producing undue traction from below. — 
Prolapsus of the vagina, bladder or rectum; lymph deposits; 

197 



198 A TEXT-BOOK OF GYNECOLOGY. 

cicatrices in vaginal walls; uterine polypi; operations on the 
uterus. 

These causes will be more fully considered in connection with 
the etiology of the respective varieties. 

I. Ascent. 

Definition. — An elevation of the uterus above its normal 
location. 

Etiology. — Ascent of the uterus takes place when pregnancy 
or a tumor enlarges the uterine body so that there is not sufficient 
room for it within the pelvis; or when a tumor occurs in the pelvis 
below the level of the uterus, or the vagina becomes filled with re- 
tained menstrual fluid, or the rectum or bladder become distended, 
producing pressure from below upward. Shortening of the utero- 
sacral ligaments, which result from inflammation, may also draw 
up the uterus, but anteflexion is the usual consequence of this con- 
dition. Ascent of the uterus is never a primary disease, and is 
only of interest as it points to other lesions of which it is only an 
accompaniment. 

2. Descent or Prolapsus of the Uterus. 

Synonym. — Falling of the womb. 

Definition. — A downward displacement of the uterus, which 
also, necessarily, includes a concurrent descent of the vesico-and 
recto-vaginal walls — the bladder, the urethra and the rectum. For 
this reason, Dr. Hart suggests the term " sacro-pubic hernia," 
rather than prolapsus of the uterus; while Hart and Barbour treat 
the condition under the head of ''displacements of the pelvic 
floor, 1 ' rather than of uterine displacements. 

Varieties. — Prolapsus may be partial or complete, the former 
varying in degree from a slight, yet perceptible, settling of the 
uterus to cases in which the os presents at the vulva. When a 
part or the whole of the organ extends from the vulva, the pro- 
lapsus is said to be complete, entire extrusion of the uterus being 
called procidentia. Dr. Thomas applies the term prolapsus to all 
cases, "marking the degree of descent by the terms first, second 
and third." 

Etiology. — Any of the causes already referred to as produc- 
ing uterine displacements in general may cause prolapsus. But it 
is seldom that any one cause, or, indeed, that any one class of 
causes, operates alone; though generally a single class of causes is 
most prominent. In my opinion, a weakening of the uterine sup- 
ports is the most frequent etiological factor in producing prolapsus 
uteri, while the dragging down produced by pre-existing prolapsus 
of the vaginal walls comes next in point of frequency. 



DISPLACEMENTS OF TEE UTERUS. 



199 



Prolapsus uteri most often follows and has its origin in the 
process of parturition, which is liable to give rise to many condi- 
tions, any one, or all, of which may cause the trouble. If there 
has been no laceration of the perineum or of the cervix uteri, 
and if involution progresses favorably, there will be no prolapsus, 
but, unfortunately, this favorable course is not always followed, 
the result being that the heavy uterus so weighs down upon the 
relaxed vaginal walls and utero-sacral supports, that they give 
way and fail to recover their normal tone and relations, so that 
some slight accident, such as a jar or cough or straining at defeca- 
tion, causes the uterus to become prolapsed. 

Prolapsus seldom occurs except in women who have borne 




Fig. 131.— To Show the Nature of Prolapsus Uteri: a, peritoneum; 6, 
bladder; c, uterus; tZ, anterior vaginal Avail; e, anterior rectal wall; f, 
perineum; g, posterior vaginal wall. The dark portions are the cover- 
ings of the hernia (after Schutz). 



children, and its frequency increases in proportion to the number 
of parturitions which have occurred. 

Mechanism and Pathology. — Much difference of opinion 
exists among gynecologists as to the mechanism and pathology of 
prolapsus, scarcely any two investigators holding precisely the 
same views. For this reason, it is hardly worth while to encum- 



200 



A TEXT-BOOK OF GYNECOLOGY. 



ber a practical work of this character with the numerous theories 
on the subject. 

The method by which the four classes of causes already men- 
tioned, either alone or combined, may cause a descent of the uterus 
under various circumstances, is too evident to require any extended 
explanation; this is true, at any rate, if the student already has 
proper knowledge of the normal anatomy of the parts. 

The mechanism of the descent of the uterus with its attach- 
ments is quite analogous to that of hernia. The vagina furnishes 
a tract through which passes the cervix uteri, followed by its 
vaginal attachments, the vagina becoming more and more inverted 
as the descent progresses, thus forming a sac which contains not 
only the uterus, but also the peritoneum and more or less of the 
.small intestines. This sac, enlarging as it descends, finally, in 




Fig. 132.— Stages of prolapsus uteri in ordinary cases. 

complete prolapsus, extends through the vulva, and lies exter- 
nally between the thighs. It then holds more or less of the pro- 
lapsed bladder which has followed the anterior vaginal wall, and 
may also include the rectum and the posterior vaginal wall, form- 
ing a pouch; but, more often, the posterior vaginal wall is peeled 
off from the rectum, leaving the latter in its normal position. The 
position of the uterus varies in its different degrees of descent, 
correspondingly with the direction of the axis of the pelvis in 
which it is engaged. The tendency is to a gradual retroversion, 
which is not only induced by the direction of the axis of the 
pelvis, but also by the fact that, as the soft parts are dragged 



DISPLACEMENTS OF THE UTERUS. 201 

clown, tension is made on the peritoneal aspect of the pubic seg- 
ment, which has the effect to throw the fundus backward. After 
complete prolapsus the os points downward and, frequently, back- 
ward. The position is, of course, more or less influenced by the 
local condition of the organ, a heavy, congested fundus tending 
to increase the retroversion, while a heavy hypertrophied cervix 
might have the contrary effect. 

According to Legendra, "the tension of the aponeurotic 
fibres of the broad ligaments, during uterine prolapsus, results in 
compression of the hypogastric veins, even as compression of the 
veins of the neck occurs from tension of the cervical fascia when 
the head is forcibly thrown backward. In this way, congestion of 
the uterus and other pelvic organs is kept up." Especially if sub- 
involution be present does the uterine congestion result in hyper- 
plasia and hypertrophy, while the tension that is continually 
present serves to draw out the uterus and increase its length. 
The endometrium becomes greatly irritated and pours forth a 
vitiated catarrhal secretion, while the cervix is frequently the seat 
of erosions and even of ulcerations. The vagina becomes swollen 
and hypertrophied, and its mucous membrane the seat of vaginitis 
and catarrh. In complete prolapsus, the mucous membrane, act- 
ing as integument, becomes hypertrophied, dry, ©edematous, eroded 
and ulcerated. Its transverse folds or rugae disappear, and a pro- 
liferation of epithelium occurs which gives it the appearance of 
epidermis, or, as Thomas says, it "looks like the cicatrized sur- 
face of scalded skin rather thnn mucous membrane.''' 

Symptoms. — In exceptional cases, prolapsus may occur sud- 
denly, and the patient experience excruciating abdominal pain, 
fainting, and profound nervous shock. More often, however, the 
descent is gradual, the patient experiencing only a sensation of 
weight and dragging in the pelvis and pain in the back and loins. 
These may constitute all the subjective symptoms, but usually, as 
the dragging down continues, and hypertrophy and other changes 
occur, the patient will have more or less rectal and vesical irrita- 
tion; walking becomes difficult and fatiguing, all physical exer- 
tion, especially the lifting of heavy weight, causes pain and 
increases the descent, and leucorrhea is present, together with 
other symptoms of congestion. In complete prolapsus there is 
more or less discomfort, sometimes extreme suffering being 
caused by the protrusion, and consequent excoriation of the 
parts. 

Physical exploration will reveal the os lying more or less 
below its normal level, according to the degree of descent, and the 
finger passed up in the front of the cervix will detect the normal 
outline of the fundus, unless some malposition be present to com- 



202 A TEXT-BOOK OF GYNECOLOGY. 

plicate the prolapsus, or unless the descent be so great that the 
fundus is already thrown backward to correspond to the axis of 
the pelvis, in which it is engaged. If the prolapse be complete, 
the physical signs are evident to both touch and sight. 

Diagnosis. — Examination for prolapsus uteri is usually made 
with the patient standing. Prolapsus may, however, be con- 
founded with hypertrophy and elongation of the cervix, with 
fibrous polypi, with inversion, and with cystocele and rectocele. 
The diagnosis of these conditions is considered under their respec- 
tive heads. 

Prognosis. — The prognosis is favorable or unfavorable in 
proportion to the degree of displacement, the length of time it has 
been present, and the nature of the complications which may exist. 
If there be considerable congestion of the uterus, with enlarge- 
ment, and more or less endometric disturbance, or if the vaginal 
walls have been greatly distended and are flabby and atrophied, 
the prolapsus may persist in spite of all treatment. Fatal cases 
are recorded where death has resulted from pelvic inflammations, 
caused by the irritation from the prolapsed uterus, or from uraemia 
caused by pressure upon the uterus, or from the uterus be- 
coming incarcerated, resulting in gangrene. No doubt, homeo- 
pathic remedies will do much toward relieving existing complica- 
tions, and restoring the uterine supports to their normal tone and 
vigor, thus rendering the prognosis more favorable than when the 
treatment consists entirely of mechanical or surgical measures. 

Treatment. — Prophylactic measures are not to be disre- 
garded. In a majority of instances prolapsus results from im- 
proper management during the puerperium. Either the patient 
gets up too early, or resorts to some exercise, either in the care of 
the child or otherwise, before involution of the organs has taken 
place. Or, laceration of the perineum may have occurred, and 
the integrity of the pelvic floor have been destroyed. The physi- 
cian should exercise his skill to prevent these occurrences. After 
labor any considerable laceration of the perineum should receive 
immediate attention, union of the parts being obtained either by 
the introduction of stitches in the usual manner (see Laceration of 
Perineum), or by the proper postural treatment as advised by some 
obstetricians. The latter consists in bringing together the knees 
and tying them, removing the urine with a catheter for several 
days, irrigating the vagina frequently with tepid water, to which 
may be added a few drops of Calendula, and by the use of 
enemata, keeping the bowels from becoming constipated. I have 
never been very successful with this method of dealing w T ith a 
recent laceration, and prefer to introduce the necessary number of 
stitches, followed by precisely the same measures as have just been 



DISPLACEMENTS OF THE UTERUS. 203 

detailed. In considering prophylactic measures it should not be 
forgotten that the application of the indicated remedy for any 
untoward symptoms that may arise either before or during the 
puerperium, may prevent a uterine displacement. No doubt when 
errors have been committed by puerperal patients, which may 
have a tendency to retard involution, and may have already 
induced some descent of the uterus, the indicated remedy and 
quiet rest in bed will overcome the evil effects, and avert what 
might otherwise prove to be a very troublesome and possibly a 
lifelong ailment. 

When prolapsus of the uterus already exists, the first measure 
to be adopted is the replacement of the organ. This is usually 
readily accomplished, but in some instances taxis becomes neces- 
sary. According to Dr. Thomas (1) this is best applied in the fol- 
lowing manner : "The patient after thorough evacuation of the 
bladder and rectum, if this be possible, should be placed upon her 
knees and chest, in order to cause gravitation of the pelvic and 
abdominal viscera toward the diaphragm. She should not kneel 
upon a soft or yielding bed, into which the knees would sink, but 
upon the floor or a table, for the object of the posture is to elevate 
the buttocks, and depress the thorax as much as possible. Ten or 
fifteen minutes should then be allowed to elapse before any efforts 
are made at reduction. In this time the intense congestion which 
exists in the pelvic viscera will greatly diminish. The operator 
then taking the cervix into the grasp of the index, middle and 
ring finger, pushes the uterus firmly and forcibly upward in coin- 
cidence with the axis of the inferior strait. While the right hand 
is thus employed, the left rests upon the back of the patient and 
steadies her body. No sudden or violent force is exerted, but by 
steady pressure, kept up, if necessary, for fifteen, twenty or thirty 
minutes, the uterus is restored to its place. Few T cases will resist 
this kind of effort at reduction, although some may do so. 1 ' 

Violent force should not be exerted unless the condition of 
the patient demands immediate reduction, as might be the case if 
the uterus were incarcerated and gangrene impending. 

The uterus having been restored to its normal position, the 
next thing is to keep it there. This should be accomplished, if 
possible, by proper posture and medicinal treatment. The patient 
should be kept in bed and the indicated remedy perseveringly ad- 
ministered. At the same time a glycerine plug should be applied 
and copious injections of hot water be used frequently. I once 
radically cured a very bad case of prolapsus of many years' stand- 
ing in this manner. In many instances, however, the patient will 
not consent to remain in bed the necessary length of time, or, if 

1) Diseases of Women, p. 342. 



204 A TEXT-BOOK OF GYNECOLOGY. 

she does, the method of treatment is unsuccessful, and it becomes 
necessary either to resort to surgical procedures or to support the 
uterus by a pessary or by some other artificial means. 

The varieties of surgical practice are: 1. Repair of the peri- 
neum (perineorrhaphy); 2. Repair of the perineum and denuding 
of the mucous membrane of the posterior vaginal wall (Elytro-per- 
ineorrhaphy); 3. Freshening the mucous membrane of the anterior 
vaginal wall (Ely trorrhaphy); 4. Freshening the mucous mem- 
brane on each vaginal wall, and stitching these surfaces together. 
The method of performing these respective operations will be 
found elsewhere in this book. 

The plan of supporting the prolapsed uterus, together with 
the vagina, bladder and rectum, by artificial means, is that adopted 
in a vast majority of cases. In rare instances this can be accom- 
plished by the use of an external bandage, but only in those cases 
where the prolapsus is kept up by undue pressure from above, re- 
sulting from the great size and weight of the abdominal tumors. 
In other cases good results are sometimes obtained from the use of 
a uterine supporter held in place by an external bandage. Theo- 
retically, supporters have many advantages over pessaries, chiefly 
in that they do not distend and irritate the vagina, nor interfere 
with the nutrition of the parts ; but, on the other hand, their use, 
according to my experience, is attended with disadvantages that 
render them less desirable than a well-adjusted pessary. Their 
most objectionable feature lies in the fact that the cervix is required 
to lie within a hard-rubber cup, which not only causes constant 
irritation of the mucous surface of the os and cervix, but also re- 
tains the secretions of the parts, and thus cervical inflammation, 
erosions and ulcerations are brought about. Dr. Ludlam says 
that "all kinds of stem supporters are likely to induce cellulitis 
or peritonitis, which may result fatally." 

Pessaries have been used in the treatment of uterine prolapse 
since the days of Hippocrates, and while they have many objec- 
tionable features, and should never be employed when their use 
can possibly be avoided, yet they are at times a necessary evil, 
and cannot be altogether dispensed with. The greatest evil lies 
in the fact that their use is seriously abused. Physicians are fre- 
quently in the habit of applying a certain kind of pessary in all 
cases of prolapsus regardless of the local conditions or of the 
causes that are inducing the displacement, or without any idea as 
to whether the pessary they are using is the proper one to apply 
in the given case. Undoubtedly the general principles attending 
the use of pessaries are wrong. They are intended to act as a 
proper support for the uterus, and sometimes when skillfully ad- 
justed, answer the purpose admirably, and the patient feels as if 






DISPLACEMENTS OF THE UTERUS. 205 

she were cured at once. But, as Dr. Winterburn says, (1) the 
relief thus obtained " is mechanical, not vital, and therefore, 
unnatural and inhibitory. Muscles act only under the incentive 
of compulsion, and when the necessity of action is withdrawn 
they become lax, atrophic, and useless. The victim of this form 
of treatment, unless other influences are brought to bear which 
more than overbalance the injury inflicted by the mechanical sup- 
port, soon finds herself utterly dependent upon it and unable to 
get about without it. A rational treatment, on the other hand, 
seeks to arouse vital action, not to suppress it ; aims to encourage 
the supporting muscles to do their duty, not to supplant them by 
foreign mechanism ; insists upon restoration of all the involved 
organs, both functionally and positionally, instead of providing 
mere temporary makeshifts, such as all mechanical supports neces- 
sarily are. The foreign body in the vagina not only deprives the 
uterus of such remnant of natural support as is still left to it, 
instead of restoring it; not only prevents nutrition of the parts 
and the full play of abdominal and respiratory movements; not 
only displaces the vaginal walls by its mere presence, and thus 
displaces every other pelvic viscus; but it prevents those natural 
oscillating and reciprocal movements of the uterus which are essen- 
tial to its nature. When it is generally recognized that the 
primary disease consists in the weakness of those parts upon 
which the uterus and its appendages depend for support, and that 
the prolapse is incidental and secondary, it will be acknowledged 
that whenever the treatment is based on mechanical supports the 
real disease is concealed rather than cured. Not only is the 
pessary unscientific in theory, but, as ordinarily used, it is provo- 
cative of much mischief. Vesico-vaginal fistula?, and other 
ulcerations, frequently result when pessaries are left in situ for 
months at a time. Dr. Marion Sims and others have mentioned 
many cases. The vaginal secretions are viscid, and incline to ad- 
here to the instrument. The deposit does harm in two ways. It 
forms a roughened crust upon the pessary, which profoundly irri- 
tates the mucous lining of the vagina ; this latter determines an 
undue flow of blood toward the parts, involving ultimately all the 
surroundiug tissues in the congestion, setting up a proliferation of 
cell-growth which not only causes a loss of much vital power, but 
gives rise to serious organic changes. Or, this deposit decom- 
poses, and the products of this decomposition are absorbed, thus 
adding a new and very grave complication. The use of a pessary 
is often provocative of flexion of the uterus, a worse condition 
than the original prolapse ; for, while it supports the uterus from 



1) Arndt's System of Medicines, Vol. II., p. 415. 



206 A TEXT-BOOK OF GYNECOLOGY. 

below, it cannot in any way modify the pressure from above, which 
is crushing the uterus downward ; and that organ, acted upon by 
these two opposite forces, bends upon itself, a condition which 
often becomes permanent and irremediable. While, therefore, a 
pessary may be of temporary benefit, and may even be used with 
advantage for a brief period in certain rare cases, the objections to 
every form of mechanical support are radical and cannot be gain- 
said. The only rational treatment, and the only one meriting our 
attention, is that which restores the efficiency of the natural sup- 
ports of the uterus." 

Notwithstanding the truth of all these statements, the practi- 
cal gynecologist is frequently obliged to resort to the use of pessa- 
ries. In those cases especially where the uterine supports are 
greatly weakened, and the vaginal walls are relaxed and feeble — 
as usually results from parturitions — and in cases occurring in old 
women, where surgical measures are not justifiable, pessaries may 
often be used with good results. They should never be employed 
if there is present any form of metritic, endometritic, peri-or para- 
metritic inflammation. A pessary that distends the vagina should 
never be worn ; nor one that causes the patient discomfort. While 
the pessary is in place the vagina should be daily irrigated with 
tepid water for purposes of cleanliness. The fitting of a pessary 
in a given case is often an extremely difficult task. On this point 
Dr. Emmett (1) says : 

kw The practitioner, to become an expert in fitting a pessary 
that it may do no harm, must have a decided mechanical talent ; 
and, that the full benefit may be derived from the use of the instru- 
ment, he must be able to appreciate slight shades of difference 
which would be entirely overlooked by others. The first is a gift, 
which cannot be acquired ; the second can be gained by experience, 
but it is of little practical value unless associated with the first. 
The great cause of failure and disappointment in the use of 
pessaries lies in the fact that the vagina is expected by many to 
adapt itself to any instrument which may be introduced, when in 
fact it is essential that the peculiarities of each individual case 
should be studied. In adjusting a pessary, the physician should 
pay as much regard to the peculiarities of shape and size of the 
vagina as the dentist does to those of the mouth when fitting a set 
of false teeth. I am fully aware that it will be considered an ex- 
travagant statement by many, but, nevertheless, I do not hesitate 
to make the assertion, that scarcely two women can be found who 
will be benefited by wearing the same shaped instrument. Fortu- 
nately, it is true, there are many women who are able to tolerate an 



1) Op. Cit., p. 



DISPLACEMENTS OF THE UTERUS. 



207 



ill-fitting instrument, without receiving injury, but they are not 
benefited, except it be by sheer good luck." 

Of the great variety of pessaries now in use, I will only men- 
tion a few kinds that seem to be best adapted for ordinary cases. 




Fig. 133.— Hodge's Pessary. 



Gt$ 



Fig. 134. — Thomas' modification of 
Hodge. 



Hodge's pessary (Fig. 133) is probably the most popular, or 
Hodge's pessary as modified by Albert Smith (Fig. 136), Emmett 
(Fig. 135), or Thomas (Fig. 134.) The smaller curve of Emmett's 





Fig. 135. — Emmett's modification 
of Hodge. 



Fig. 136.— A. Smith's modification 
of Hodge. 



modification of Hodge will answer the average indication more 
nearly than the sharper curve of the Albert Smith modification, 
but the latter will answer best when it is required to lift the uterus 
high in the pelvis. I have found the Fowler pessary (Fig. 137) 




Fig. 137.— Fowler's Pessary. 

to be an excellent instrument. In fact I think that it will, in its 
various sizes, answer the indications in ordinary cases more nearly 
than any other pessary. As the general practitioner can hardly 
keep an adequate variety of pessaries on hand, it will be found a 
good plan to use those made of block tin, which can be moulded 
to suit each individual case. Ring pessaries, as a rule, are not 
satisfactory, but are sometimes required. Meig's 



208 A TEXT-BOOK OF GYNECOLOGY. 

(Fig. 138), and especially Thomas' modification of Meigs, (Fig; 
139), are considered the best. In old cases, where other methods 





Fig. 138. — Meig's Ring Pessary. Fig. 139. — Thomas' modification of 

Meig's Ring Pessary. 

have failed, the patient can be instructed how to pack the vagina 
once or twice a week with marine lint. 




Fig. 140. — Zwanck's Pessary. 

Whether pessaries are used or not, it is important that all 
superincumbent weight be removed from the abdomen. The 
clothing should be loose, the weight of the skirts should be sup- 
ported from the shoulders, and the wearing of a corset prohibited. 
At the same time the patient should avoid any lifting or muscular 
exercise, and long standing or sitting without change of position. 

The medical treatment of displacements has not received the 
attention which its merits demand. As has already been intimated, 
in attending to the local conditions we often lose sight of those 
constitutional disturbances which, whether the cause or the result 
of the prolapsus, have much to do with its prolonged existence. 
These may usually be controlled by the appropriate homeopathic 
remedy, which may also cover the local indications as well, and a 
permanent cure result. Many authenticated cases are reported 
where prolapsus and other forms of displacement have been per- 
manently cured by administration of the appropriate internal rem- 
edy. The remedies most often used, in the order of their prob- 
able value, are Sepia, Pulsatilla, Lilium tig., Belladonna, Nux 
vomica, and Podophyllum, but it must be remembered, as I have 
elsewhere remarked, that the totality of the symptoms alone must 



DISPLACEMENTS OF THE UTERUS. 209 

guide to the selection of the remedy, but as the choice may fall in 
very many directions, I can hardly occupy the space necessary to 
mention the names of the possibly indicated drugs, much less give 
their special indications, for which I must refer the reader to our 
works on Materia Medica, or to Dr. Winterburn's excellent art- 
icle in Arndt's System of Medicine. 



CHAPTER XXIII. 
ANTEVERSION. RETROVERSION. LATEROVERSION. 

3. ANTEVERSION. 

Definition.- — Anteversion consists in an obliteration of the 
physiological angle of flexion, the cervix pointing toward the 
sacrum while the normal tilt forward of the fundus is increased. 

Pathology and Etiology. — Generally as a consequence of 
chronic metritis or of subinvolution, the uterus becomes infiltrated 




Fig. 141.— Anteversion of the uterus: 1, the rectum; 2, lying upon the 
uterus; 3, the fundus uteri; 4, the bladder; 5, the urethra; 6, the 
vagina. 

and hard, and the physiological angle of flexion is obliterated, 
thus straightening the uterus; frequently some perimetritic in- 
flammation causes adhesion of the cervix above, or of the fundus 
below. When the anteversion is first discovered the metritis may 
have disappeared, but the uterus remains fixed in its abnormal 
position by the adhesions. Increased weight from an interstitial 
fibroid may depress the fundus and cause anteversion. As 
chronic metritis or subinvolution are the chief causes of antever- 
sion, it follows that we are most apt to meet with this displace- 
ment after parturition or abortion, and that it results secondarily 
from the same class of causes as will produce the conditions named. 
It is a comparatively rare affection, occurring much less fre- 

210 



ANTE VERSION OF THE UTERUS. 211 

quently than retroversion. The anteversion met with in early 
pregnane}' is physiological. 

Symptoms. — These are such as result from the metritis and 
other complications, rather than from the displacement itself. The 
pressure of the fundus against the bladder often produces vesical 
irritation, even to cystitis, while the cervix pressing in a like 
manner against the rectum may cause more or less rectal irrita- 
tion and pain in defecation. As a rule, the bladder symptoms 
are most constant and distressing. In exceptional cases the patient 
suffers only daring the menstrual period, at which time the blood 
collecting in the fundus causes dysmenorrhea. There is, in most 
cases, more or less difficult}' or discomfort in locomotion. 

Diagnosis. — This can be readily determined by vaginal touch, 
which discloses the cervix lying toward the hollow of the sacrum, 
the fundus resting upon the bladder, the outline of the uterus 
being readily traced with the finger, which also discloses that the 
normal angle of flexion is absent. The sound can only be used 
with great difficulty, and it is usually unnecessary. Bi-manual 
examination will show the size and shape of the organ, and the 
amount of fixation, and will usually settle the question whether 
or not the body felt anteriorly is the fundus uteri. If this is not 
clear, a rectal examination will decide whether the uterus is retro- 
verted or not. 

Prognosis. — It is very difficult, to begin with, to replace an 
anteverted uterus that is bound down by adhesions, and, secondly, 
it is equally difficult to retain it in the normal position after 
replacement. Yet, notwithstanding these facts, the prognosis, as 
regards great improvement, and. possibly, cure, is usually favor- 
able. Mechanical treatment is of chief importance in cases of long 
standing, while in recent cases careful medication conjoined with 
rest and hygienic measures, is often all that is required. Fritsch 
says that, "if the complications be removed, the dislocation^? 1 se 
does no harm," but I do not think, that this is always true, for 
the displacement itself may produce very serious vesical troubles, 
if nothing more. Pregnancy is said to sometimes produce a cure. 

Treatment. — In recent cases the treatment is, usually, that 
which would be adopted for chronic metritis, or less often pelvic 
cellulitis or fibroid tumors, the' reader being referred to these sub- 
jects elsewhere considered. Such treatment should be supple- 
mented by measures that tend to restore the normal position of 
the uterus, of which the dorsal decubitus is most important. While 
any considerable degree of inflammation is present no effort should 
be made to forcibly replace the uterus, though a glycerine plug 
may be, each day, crowded up against the fundus. 

After the inflammation has almost disappeared, if adhesions 



212 A TEXT-BOOK OF GYNECOLOGY. 

are not present, the uterus can usually be replaced without diffi- 
culty. In order to accomplish this, the patient having emptied 
the bladder and removed any tight clothing from around the waist, 
should lie upon her back on a table or hard bed. The operator 
then places two fingers of the right hand against the fundus of the 
uterus, using the left hand to push up the abdominal viscera. The 
patient is then directed to take a deep inspiration, expiring the air 
slowly. As the air is being expired the operator firmly and 
steadily presses against the fundus, at the same time pushing up the 
abdominal viscera with the left hand. If the uterus tends to sink 
back immediately to its former position, the fundus may be sus- 
tained by the left hand on the abdomen, while the finger of the 
right hand is placed back of the cervix, and the latter drawn for- 
ward. After the uterus is replaced it becomes necessary to adopt 
methods to prevent its return, which otherwise it will almost in- 
variably do. The patient should be instructed to assume the 
dorsal decubitus as often and as long each time as possible; espe- 
cially should she do so during the middle of the day, if she is 
obliged to be on her feet more or less at other times. She should 
be instructed to retain the urine each time as long as possible, and 
should be prohibited from wearing any tight clothing, or having 
her skirts supported from the waist. At the same time she may 
obtain considerable benefit from wearing an external abdominal 
support, especially if she be corpulent. A glycerine plug packed 
in the posterior fornix behind the cervix is often very beneficial. 





Fig. 142.— Graily Hewitt's Cradle Fig. 143.— Gehrung's Anteversion 
Pessary. Pessary. 

If these methods do not prove sufficient it will be necessary to in- 
troduce a pessary. A simple ring pessary along the posterior 
vaginal wall will probably answer the best purpose. Introduce 
the pessary with a pair of dressing forceps, until it can pass no 
farther, or causes pain, when the forceps-blades are to be separated, 
and the ring opens, drawing the cervix into its lumen by atmos- 
pheric pressure. The uterine body being inflexible follows the 



RETROVERSION OF THE UTERUS. 213 

movements of the cervix and becomes elevated to its proper posi- 
tion. Various forms of pessaries have been devised for ante- 
version, but I consider the ring superior to any of them. Graily 
Hewitt's "cradle pessary" (Fig. 142), Gehxung's pessary (Fig. 
143), Thomas' anteversion pessary (Fig. 144), and Hitchcock's ante- 
version pessary (Fig. 145), all have their advocates. The best rule 
to follow is never to use a pessary of any kind if it can possibly be 
avoided, and where it cannot, to use the simplest contrivance possible. 
Aurum, Belladonna, Calcarea, Ferrum, Lilium tig., Mercu- 
rius, Nux vom., Platina, Sepia and Stramonium, are the remedies 
especially recommended by Dr. Lilienthal in anteversion, but the 




Fig. 144. — Thomas' Anteversion Fig. 145. — Hitchcock's Anteversion 
Pessary. Pessary. 

symptoms alone must decide as to their application. I think it 
can hardly be said that any one class of remedies is most useful in 
this particular form of displacement. As a rule, the remedies that 
will be called for are those most often used in chronic metritis, to 
the article on which the reader has already been referred. 

4. Retroversion. 

Definition. — Retroversion is that malposition of the uterus 
in which the fundus lies tilted back toward the sacrum, while the 
cervix is directed forward toward the symphysis pubis. 

Etiology and Pathology. — Whenever the bladder is dis- 
tended to its fullest extent it causes a retroversion that is physio- 
logical, the uterus returning to its normal position after urination. 
If, however, there is present in the uterus any pathological con- 
dition, such as a tumor — especially if it be in the posterior wall, 
which makes the uterus heavy — or if there be a weakness of its 
anterior ligamentous attachments, the uterus may not return to its 
proper position after urination, and a pathological retroversion 
results. So, too, when the uterus is retro verted by a full bladder, 
in the manner described, if the patient falls backward, or if she 
slip, or strain herself, so as to give the organ a still greater im- 
petus backward, the uterus may not return to its normal position. 
After parturition as the patient lies upon her back, the uterus is 
retroverted, a state which is physiological, but sometimes, from 



214 



A TEXT-BOOK OF GYNECOLOGY. 



subinvolution or other cause, the uterus fails to resume its normal 
position and the retroversion persists. According to Winckel, (1) 
" when instrumental deliveries, such as extraction with the forceps 
before complete dilatation of the os, or accouchement force in pla- 
centa prsevia, have lacerated the vaginal vault and cervix, and the 
anterior lip has become distorted from cicatrization, so that the 
vaginal portion is drawn up against the anterior pelvic wall, the 
bladder will gradually force the body of the uterus backward. 
The inflammatory processes which almost invariably follow such 




Fig. 146. — Retroversion of the uterus. 



injuries confine the patient in bed, where she lies in the dorsal 
position, and this favors the inclination of the cervix to the ante- 
rior pelvic wall, and promotes the formation of adhesions between 
the uterine fundus and the rectum." 

Pelvic inflammation behind the uterus may produce adhesions 
or cicatricial bands, and drag the uterus backward. Retroversion 
may also occur in the mechanism of prolapsus uteri, as well as in 
that of retroflexion, it being not an uncommon thing, especially in 
married women, to have an ordinary retroversion end in a retro- 
flexion. According to Fritsch, (2) "If the fastenings are rela- 
tively firm and the body relaxed, the latter becomes flexed — retro- 
flexion arises. On the contrary, if the fastenings are lax and the 
body firm, badly involuted, stiff, chronically inflamed and heavy, 
the uterus descends, inverting the vaginal vault — the process of 
prolapsus begins. 1 ' 

Symptoms. — Here, as in other forms of uterine displacement, 



1) Diseases of Women, Parvin. p. 313. 

2) Diseases of Women, W. Wood & Co., p. 192. 



RETROVERSION OF THE UTERUS. 215 

it may be difficult to determine whether the symptoms arise from 
the retroversion or from the complications which exist with it. 
Ordinarily, the patient complains of bearing-down sensations, a 
feeling of heaviness in the pelvis, exhaustion and discomfort from 
walking or standing, vesical tenesmus, pain on defecation, and 
constipation. The vesical tenesmus is caused by the dragging 
back of the bladder by the retroverted uterus, preventing it from 
completely contracting. This may also cause a flexure of the 
meatus, or the cervix may press against the meatus, causing com 
plete retroversion. At the same time the fundus presses against 
the rectum, causing difficulty and pain in defecation, and even 
constipation, hemorrhoids and ulceration. 

In recent cases occurring during the puerperium, hemorrhage 
is a prominent symptom. This may be severe, but more often it 
is slight, and is considered by the patient as commencing menstru- 
ation. Retroversion sometimes occurs suddenly, from a fall or 
blow, the symptoms being very severe. The patient falls to the 
ground and is unable to rise, experiences the severest pelvic pain, 
suffers from suppression of urine and retention of feces, and is 
often in such agony that the face is bathed with perspiration and 
the pulse becomes weak and fluttering. 

Physical examination reveals the cervix lying toward the 
symphysis pubis, and the finger can trace the outlines of the uterus 
backward until the body of the organ is found resting upon the 
rectum. The greater the degree of displacement, the more accu- 
rately can the outlines of the fundus be made out. 

Diagnosis. — In most instances a vaginal examination reveal- 
ing the conditions just described is all that is necessary, but should 
there be any doubt, a rectal examination will more clearly reveal 
the outlines of the fundus. It may also be necessary to pass the 
uterine probe in order to be certain of the direction of the uterine 
axis. Bi-manual examination will show the absence of the fundus 
from its normal location. 

Retroversion is most apt to be confounded with a fibroid 
tumor on the posterior wall, or with the results of pelvic inflam- 
mation, but the history of the case and the physical signs are 
usually sufficient to establish the diagnosis. 

Prognosis. — With appropriate treatment the prognosis is 
usually favorable, but in cases in which the uterus is bound down 
by strong adhesions, or when an interstitial fibroid tumor is 
present, the displacement may persist in spite of all treatment. 

Treatment. — The first indication for treatment is to remove 
any inflammation that may exist, which is to be accomplished ac- 
cording to methods which have already been considered under the 
various forms of pelvic inflammation. The patient should at all 



216 A TEXT-BOOK OF GYNECOLOGY. 

times be careful not to lie continually upon the back, and should 
evacuate the bladder frequently. The next indication is to replace 
the uterus. In order to accomplish this the patient should assume 
the knee-chest position, after which the operator introduces two 
fingers into the posterior cul-de-sac, their palmar surfaces facing 
the rectum, and makes firm pressure upon the fundus. If this is 
not sufficient, the index finger may be introduced into the rectum 
and pressure made against the fundus, or Guernsey's uterine ele- 
vator may be used for this purpose. This instrument (Fig. 147) 



Fig. 147. — Guernsey's Uterine Elevator 




consists of a curved steel rod about eight inches in length, pro- 
vided with a handle at one end, while on the other there is a 
round ivory ball about three-fourths of an inch in diameter. 
After lubricating the ball it is gently introduced into the rectum, 
with the handle upward. The instrument is then carefully pushed 
forward, the handle being sufficiently elevated to allow the ball to 
press against the anterior wall of the rectum. As the latter pushes 
against the fundus, if there are no adhesions, it will cause the 
uterus to return to its normal position. Should the ball slip over 
the fundus, it must be drawn back and the effort repeated. In 
some cases it may be necessary to increase the leverage by making 
traction upon the cervix per vaginam, at the same time that pres- 
sure is made upon the fundus per rectum. Some physicians use 
a sponge fixed in a sponge holder, with which they press against 
the fundus, or have two sponges thus fixed, carrying one into the 
rectum and the other into the vagina. 

If all these means fail, it is altogether likely that the uterus 
is bound down by adhesions. At all events, I would not advise, 
in such cases, any efforts to restore the organ by means of instru- 
ments which are introduced within its cavity, as they are liable to 
injure the uterus and create inflammation. In cases where but 
little force is required, some prefer to the methods already men- 
tioned, the use of Elliott's uterine repositor (Fig. 148), or, what is 
still better, of Sims' uterine repositor (Fig. 149). I do not favor 
the use of such instruments, for they are not very effective, and 
are often dangerous. I consider the sound a better instrument 
with which to elevate the uterus, if any intrauterine contrivance 



RETROVERSION OF THE UTERUS. 



217 



Is to be used. The method of using the sound is to introduce it 
into the uterus, and allow it to follow the carve of the organ back- 
ward, after which the sound is made to slowly revolve one-half, 
the handle being at the same time gradually elevated until the 







-concavity of the sound is upward. The left hand is then placed 
under the sound near the vulva, thus constituting a fulcrum, the 
sound being the lever, the handle of which is gently and steadily 



218 



A TEXT-BOOK OF GYNECOLOGY. 



pushed back to the perineum, and the uterus carried into position. 
Ordinarily, however, pressure upon the fundus per vaginam is all 
that is required. In some instances the mere assuming of the 
knee-chest position and separating the walls of the vagina to allow 
the admission of air causes the uterus to be restored to its proper 
position without any manipulation. 

After the uterus has been replaced the patient should remain 
in bed for several days, lying mostly upon her side and face, and 
should at intervals through the day, for a few minutes at a time, 
assume the knee-chest position, at the same time separating the 
lips of the vulva to allow the admission of air. During this time 
the indicated remedy should be persistently administered. 

If these methods fail to effect a cure, it will be necessary to 
again replace the uterus and hold it in position by an artificial 
support. The latter may consist of a glycerine plug renewed 
daily and placed in the posterior cul-de-sac, but more often some 
form of pessary will be required. The pessaries most often useful 
in retroversion are the modifications of Hodge, which have already 
been described in the article on Prolapsus of the Uterus and those 
shown in Figs. 150, 151, and 152. Great care should be taken to 
have a pessary that fits perfectly. No pessary should be allowed to 




Fig. 150. — Thomas' Retroversion 
Pessary. 




-Hoffman's Retroversion 
Pessary. 



remain when the patient is conscious of its presence otherwise 
than by the relief which it affords. 

The method of introduction in retroversion is as follows: 
After the uterus has been replaced the patient is caused to assume 
the semi-prone position, and the pessary, well lubricated, is intro- 
duced, the cervix curve next to the rectum and the uterine upward, 
being careful that the latter does not catch on the cervix, it being 
important that the cervix be engaged in the lumen of the pessary. 

There is no rule by which it can be determined in advance 



LATEROVERSION OF THE UTERUS 219 

just how long the patient will need to wear a pessary in order to 
accomplish a cure, but whether the time be long or short, the 
pessary should never be worn any longer than really necessary. 
In those cases of retroversion accompanied by hemorrhage, which 
sometimes occur after childbirth, hot water injections should be 




Fig. 152. — Byford's Retroversion Pessary. 

used to avert the hemorrhage, provided an immediate replacement 
of the uterus does not accomplish the purpose, as it usually does. 

5. Lateroversion. 

Definition. — Lateroversion consists in a tilting of the uterus 
either to the right or left side. 

Etiology. — This is a rare displacement, and is generally the 
result of pelvic exudation, which tends to fix the uterus in its ab- 
normal position; but it may arise from other causes, such as 
metritis or inflammation of the broad ligament, and it is supposed 
to be sometimes congenital. Schrceder says that a slight tendency 
of the fundus to lean toward one side, usually the right, is physio- 
logical. 

Symptoms. — These are usually slight, as neither the cervix 
nor the fundus impinges on the bladder or rectum. The diagnosis 
can only be arrived at by a physical examination. 

Treatment. — Usually no treatment is required, but symp- 
toms may arise which should be combated with the indicated 
remedy. If pelvic exudations exist, efforts should be made to 
cause their removal by the usual means. The patient should lie 
as much as possible on the side opposite to that toward which the 
uterus tilts. A pessary is not usually required, but in case it is, 
the same principles must govern its use as in other forms of 
version. 



CHAPTER XXIV. 



6. ANTEFLEXION. 



Definition. — By anteflexion is understood a pathological 
exaggeration of the normal forward bending of the uterus; the 
angle of flexion remaining rigid under all conditions, and not 
yielding to the influence of a full bladder or other circumstances 
which usually affect the position and angle of a normally mobile 
uterus. 

Vakieties. — Unfortunately it has not been customary to dis- 
tinguish any varieties of anteflexion, but as these are readily rec- 




Fig 153. — Anteflexion of the uterus. 



ognized, and as treatment can only be successfully applied 
according to the location of the flexion, it follows that a division 
based upon the location is practicable and desirable. We may, 
therefore, distinguish three forms of anteflexion : — 

1. Corporeal flexion, the cervix being normal in position 
and the body flexed. This form is rare. 

2. Cervical flexion, the body being normal in position and 
the cervix flexed. This is the most common form. 

3. Cervico-corporeal flexion, both cervix and body being 
sharply flexed. This variety may be either congenital or acquired. 

Etiology. — Congenital anteflexion is not due to defective 
foetal development, but to a failure of the uterus to properly de- 

220 






ANTEFLEXION. OF THE UTERUS. 221 

velop at puberty, which failure usually extends also to the uterine 
appendages, ovaries and vagina. Acquired anteflexion most often 
results from a prior pelvic inflammation, which may either act di- 
rectly, by dragging down the fundus or by pulling the cervix for- 
ward, or indirectly, by retracting the sacro-uterine ligaments, the 
cervix being thus drawn upward and backward, and the fundus 
thrown slightly forward. Schrceder holds that this retraction of 
the cervix is produced by adhesions resulting from peritonitis. 
The products of inflammation may also cause a thickening of the 
posterior wall of the uterus, while prolonged pressure causes a 
corresponding atrophy of the anterior wall at the angle of flex- 
ure. It is important to establish the nature of cases resulting 
from pelvic inflammation, as in such cases, according to Hart and 
Barbour, hasty operative procedures are contra-indicated, and the 
prognosis as to cure is unfavorable. 

Anteflexion may also be caused by an increased weight of 
the fundus, due to the presence of a fibroid tumor. It may also 
arise from an unequal growth of the uterine walls, or from an un- 
equal involution. 

Symptoms. — These are quite indefinite. Dysmenorrhea is 
probably the most common symptom, and that which most often 
causes the patient to seek advice. It is usually of the obstructive 
variety, and is caused by the diminished calibre of the canal cre- 
ated by the flexion. This obstructs the free exit of the menstrual 
fluids, which, being coagulated, are retained, and thus excite mus- 
cular contractions in effort at expulsion. In some instances the 
dysmenorrhea is congestive, caused by obstruction in the veins at 
the angle of flexure, which results in congestion of the body of 
the uterus, the pain being due to the resistance which the muscu- 
lar tissue offers to this hyperemia. This engorgement of the 
uterus sometimes causes the canal to be temporarily straightened, 
which removes the cause of the congestion, and the flow being 
established, the patient is relieved. 

Irritation of the bladder, with frequent micturition, or incon- 
tinence or retention of urine, may be present, but often there are 
no bladder symptoms at all. If there be any considerable degree 
of pelvic congestion there will be more or less pain over the hypo- 
gastrium, and in the groins and back, and, if endometritis be 
present, leucorrhea, but these are not due directly to the displace- 
ment, and are often absent. The patient often complains of pain, 
and difficulty in locomotion, which sometimes disappears at once 
when the displacement is restored, but in other cases it does not, 
and the symptom is evidently of mental rather than of physical 
origin. I have found more or less hysteria associated with almost 
every case of anteflexion that I have been called upon to treat, 



222 A TEXT-BOOK OF GYNECOLOGY. 

though this is not usually considered symptomatic. Sterility is 
nearly always present, and whether due entirely to the contraction 
of the canal preventing the entrance of the spermatozoa is not 
certain, though quite probable. This is, perhaps, the reason why 
anteflexion occurs most often in nulliparae. There is often a sen- 
sation of sinking, or "goneness, 1 ' at the epigastrium, and some- 
times pain on sexual intercourse. If the uterus be enlarged, or 
endometritis be present, there may .be menorrhagia. 

Diagnosis. — Physical exploration usually reveals the cervix 
in about a normal position, and, as the finger traces its anterior 
surface, the fundus will be found in the anterior fornix, while the 
distinct angle created at the point of flexion may be readily dis- 
tinguished. The bi-manual examination is necessary in order to 
determine the shape, size and sensitiveness of the uterus, and also 
sometimes to verify the presence of the fundus in the anterior for- 
nix. It is important to ascertain if pelvic inflammation be present, 
or whether the displacement be clue to the results of any prior in- 
flammation. Examine carefully the posterior fornix to see if 
there are any bands drawing the cervix backward ; try whether 
bringing the cervix forcibly forward causes pain, which would in- 
dicate an inflammatory condition in the utero-sacral ligaments or 
the presence of adhesions in the pouch of Douglas. We can 
ascertain this even better by passing the middle finger into the 
rectum, the index finger being in the vagina, and at the same time 
making the bi-manual examination. The finger in the rectum feels 
a pouch in the anterior rectal wall, bounded by a tense band on 
each side (utero-sacral ligaments), or one or more cord-like adhe- 
sions (the result of former peritonitis), or a general resistance to 
pressure which produces pain. Any of these conditions indicates 
that the cause has been inflammation, which has produced cicatri- 
zation behind the cervix." (1) If the means already mentioned are 
not sufficient, the sound, curved to correspond to the angle of the 
flexion, may be introduced, to show the direction of the uterus, 
its length, and the sensitiveness of its walls. If there is difficulty 
in passing the sound beyond the point of flexion, this may be over- 
come by drawing down the uterus with a volsella, or pressing the 
fundus upward with the finger or suitable instrument. The sound 
should not be used if active cellulitis be present. Anteflexion is 
most apt to be confounded with a fibroid in the anterior wall of 
the uterus. In such a case the sound would show the normal axis 
or a backward direction of the uterus, and the sound could not be 
felt through the anterior fornix. The same would be true if a 
cellulitic deposit were present in the anterior fornix. 



1) Hart and Barbour, Op. Cit.. p. 324. 



ANTEFLEXION OF THE UTERUS. 223 

Prognosis. — According to Thomas, (1) the prognosis as to 
cure will depend upon the following circumstances :- — 

(a) It is better in muciparous than in nulliparous women, 
because the vagina in the former more readily admits of the use 
of mechanical supports, and because it is acquired and not congen- 
ital. 

(b) It is better in pure corporeal anteflexion than in those 
varieties in which the cervix is affected. 

(c) Where the cervix is thrown far back and lifted high in 
the pelvis, the prognosis is decidedly unfavorable, and more 
especially, if there exist only a scanty vaginal pouch anterior to the 
neck. 

(d) If the flexion be of a reducible kind, prognosis is favor- 
able ; if the contrary, it is by no means so. 

(e) The prognosis of congenital flexion is almost a hopeless 
one, unless the knife be resorted to. 

(f) Of all the cases, except the last, the prognosis is most 
unfavorable in those in which the vagina joins the cervix very low 
down, near the os externum, and where the uterus is held high in 
the pelvis. 

Treatment. — The first indication for treatment is to remove, 
by the usual methods, any pelvic inflammation that may be pres- 
ent, and also to administer the indicated remedy. In some 
instances a chronic metritis or cellulitis may so complicate the case 
that direct treatment of the displacement is contra-indicated, and 
we are obliged to be content with such treatment and palliation as 
the general health and circumstances of the patient demand. Cer- 
tainly no active treatment for the displacement should be inaugu- 
rated while pelvic inflammation exists. 

The direct treatment of anteflexion differs very materially 
from that of other displacements, especially those that have 
already been considered. Here the object is not alone to return 
the fundus to its normal position and hold it there, for such a course 
would not obviate the flexion, except in rare cases where there 
existed no pathological rigidity or hyperemia, and, in such, 
treatment is usually not required. It should be the rule not to 
interfere with an anteflexed uterus unless it has induced symp- 
toms which demand relief. Most often these symptoms are those 
of dysmenorrhea, and the treatment required is to straighten the 
uterine canal. This cannot be done by the aid of ordinary pessa- 
ries, but requires either (a) dilatation, (6) the intra-stem pessary, 
or (c) a division of the cervix. 

(a) Dilatation. — This may sometimes be accomplished to a 
sufficient degree by the introduction of the sound two or three 

1) Op. Cit., p. 404. 



224 



A TEXT-BOOK OF GYNECOLOGY. 



times a week. This should be very carefully clone, no force being^ 
used, otherwise the operation is attended with some danger. Two or 
three times during the intermenstrual period, it is well, after having 
introduced the sound, to raise the body of the uterus to its normal 
position, or even to retrovert it to some extent by a careful rota- 
tion of the sound. If the ordinary uterine sound proves insuffi- 
cient, steel sounds of gradually increasing calibre may be used. 
(See chapter on Instrumental Examination.) Various dilators have 
also been used, but I prefer Molesworth's acme dilator, which has 
answered an excellent purpose in my hands. Dilatation with tents 
affords only transient relief ; it is always dangerous, and of late is 
seldom resorted to. 

Some gynecologists strongly recommend Ellinger's plan of 
rapid dilatation, but as the operation is fraught with great danger, 
especially in the hands of an inexperienced operator, and one who is 
not fully acquainted with all the requirements of uterine surgery, 
I will simply make this mention, and refer the reader to a con- 
tribution on the subject by Dr. Goodell (1) for further information. 

(b) Intra-Stem Pessaries. — Were it not for the constant 
danger attending its use, the intra-stem pessary would best fulfill 
the indications for straightening the uterine canal, as, being 
allowed to remain in situ, it may hold the uterus in position until 
the anterior wall becomes sufficiently stiffened, so that the flexion 
does not return. It has quite often proved effective, but its- 
use is hazardous, even when carefully applied, it is seldom 



C«-:;"--"---- 




Fig. 154. — Chapman's Intra-Uterine Stem Pes 



i'J' 



resorted to. I have several times used Chapman's intra-uterine 
stem pessary [Fig. 154] with good results. Jackson's elastic-stem 
pessary [Fig. 155] is highly praised by many, but I agree with Dr. 
Pratt, of Chicago, that Dr. Jackson's ; ' process is so 
slow and tedious that it is scarcely worth while to 
comment upon it." 

(c) Division of the Cervix. — This method of 
treatment is applicable only to those cases where the 
flexion is cervical, and also where the flexion, though 
but slight, is complicated with stenosis. The several 
methods of operating are described in the chapter on 
Stenosis. 

In cases where the flexion is well marked, 
Marion Sims' method may be employed. It consists 




1) American Journal of Obstetrics, 1884, p. 1179. 



ANTEFLEXION OF THE UTERUS. 225 

in dividing the posterior lip about half way from the vaginal 
insertion, and also dividing the mucous membrane of the anterior 
wall at the seat of flexion, the object being not only to enlarge the 
canal, but to cause its axis to become more conformable to that of 
the body. The lines of incision are shown in Fig. 156. The 




Fig. 156.— Sims' Division of the Cervix: a, incision in posterior lip; b, 
incision at knee of flexion (Marion Sims). 

incision must be kept open for some time by occasionally passing 
a bougie, or by introducing a glass or vulcanite stem pessary. If 
this is not done, the wound will soon close by cicatrization, and the 
operation prove a failure. Dr. Nott, in these cases, practices re- 
moving the entire posterior of the wall of the cervix, as near as 
possible to the vaginal juncture. 

The constitutional treatment of patients suffering from ante- 
flexion should not be overlooked. The persistent application of 
the indicated remedy for the symptoms that may arise from time 
to time will have much more to do with the ultimate cure of the 
displacement than is usually supposed by those who see in any dis- 
placement only a mechanical deformity, entirely overlooking the 
causative influences of a constitutional character. 



CHAPTER XXV. 

RETROFLEXION. LATEROFLEXION . 
7. Retroflexion. 

Definition.— By retroflexion is understood a bending back- 
ward of the body of the uterus toward the sacrum. It usually 
results from and is always associated with retroversion, but for 
convenience the double displacement is known as retroflexion, in 
order to distinguish it from simple retroversion, already described. 

Pathology. — The pathological conditions consequent upon 
retroflexion require a brief notice, as this displacement, with its 




Fig. 157. — Retroflexion of the uterus. 

associated disturbances, constitutes the most frequent and most im- 
portant form of gynecological disease with which we have to deal, 
excepting, however, pelvic inflammations and cervical endometritis, 
and even these are frequent complications of retroflexion. The 
uterus is bent upon itself at or about the os internum, the fundus 
lying more or less down the pouch of Douglas, pressing against 
the rectum. The size of the uterus is increased, the walls being 
usually thickened, and the cavity, as shown by the sound, some- 
what lengthened. There is usually a thinning of the posterior 
wall at the point of flexion, though this is not always the case. 
Sometimes in recent cases a swelling of the tissue is observed at 
the point of flexion, this afterward disappearing and atrophy tak- 
ing its place. In cases of very long standing it is not unusual to 

226 



RETROFLEXION OF THE UTERUS. 227 

find the entire uterus atrophied and hardened. The fundus is 
usually freely movable, and easily replaced, but not infrequently 
it is bound down by adhesions to the adjacent tissues. In some 
cases the uterus appears to be adhered, but farther investigations 
prove to the contrary. This has been explained by the fact that 
u the retro-sacral ligaments may grasp the fundus laterally, and so 
temporarily retain it in situ." The cervical canal becomes partly 
closed, but on account of the fact that retroflexion usually occurs 
in multipara?, where the os is more or less patulous, the symptoms 
resulting from constriction — dysmenorrhea and sterility — are not 
so frequent or persistent as they are in anteflexion. If lacerations 
are present, the anterior lip of the os is drawn upward, causing 
eversion, and consequent erosions and ulcerations. 

The ovaries are usually dragged down by the displaced fun- 
dus, and often may be felt at either side or behind it. They are 
frequently enlarged and tender upon pressure, and sometimes be- 
come adherent to the uterus or to the peritoneum. 

According to Hart and Barbour, (1) tL The peritoneum is 
altered in its normal relations as follows: The broad ligaments 
have their surfaces reversed; that is to say, the anterior, which was 
formerly inferior, is now superior; from their attachments they 
offer no obstacle to retroflexion. The utero-vesical pouch is neces- 
sarily obliterated. The pouch of Douglas must, on the other 
hand, be distended by the fundus uteri; this implies a stretching 
of the utero-sacral ligaments associated with the alteration in 
position of the cervix. 

' ' The pelvic nerves are occasionally affected, as shown by 
weakness in the lower limbs. This loss of power must be pro- 
duced reflexly ; from the anatomical relations, the retroflexed 
fundus cannot compress the motor nerves of the sacral plexus, as 
is sometimes affirmed." 

Etiology. — In a majority of cases retroflexion arises from 
retroversion. According to Fritsch (2), the mechanism of the 
transition is as follows: "The fastenings of the uterus do not 
yield ad infinitum; the intestines rest upon the anterior surface of 
the uterus; every increase of the intra-abdominal pressure adds to 
its weight. When the uterus involutes it becomes flexible, the 
upper half gradually bends more and more backward from the 
lower half. As there is still a certain amount of resistance at the 
angle of flexion, the vaginal portion follows the movement; that is 
to say, the more the fundus falls backward and downward, the 
more the vaginal portion glides forward and upward. Hence 
there is a stage of transition in which the uterus at times roofs 



1) Op. Cit., p. 340. 

2) Diseases of Women, W. Wood & Co., 1883, p. 



228 A TEXT-BOOK OF GYNECOLOGY. 

over the pelvis, as in anteversion, bat in the opposite direction. 
The uterus at that time is often soft, so soft that it may be in- 
dented, that thin pessaries leave grooves within it, that the com- 
pression from behind, rectum, and from in front, bladder, renders 
the body shorter and broaden But gradually the fundus must 
sink more and more downward, the vaginal portion moving for- 
ward. Thereby the body, as it were, bores its way between the 
vaginal portion and the rectum, until the fundus rests upon the 
floor of the fossa of Douglas." 

If retroflexion is thus secondary to retroversion, it naturally 
follows that the course of the retroversion already described may 
be considered as the primary cause of retroflexion. The body of 
the uterus is nearly always enlarged and heavy from subinvolu- 
tion, or chronic metritis, its walls soft, its ligaments and the tis- 
sues of the pelvic floor lax and yielding, so that any of the causes 
named under retroversion may readily obtain. A fibroid tumor 
in the posterior wall may also cause retroflexion. The causes of 
the few cases occurring in nulliparae are not precisely known. 

Symptoms. — These are numerous and varied in their char- 
acter, depending not only upon the changes in the uterus itself, 
and the influences of the dislocation upon adjacent organs and 
tissues, but also upon reflex disturbances and the associate effects 
upon the general health. The most important symptoms are 
weakness and aching in the back; weight in the rectum, tenesmus 
and painful defecation; leucorrhea; dysmenorrhea; menorrha- 
gia; symptoms of chronic pelvic peritonitis; neuralgia; neurasthenia; 
sterility; abortion; hysteria, and other nervous disturbances. 

The first symptoms named are the most constant. Dys- 
menorrhea, though frequently present, is not so common or severe 
as in anteflexion, owing to the fact that retroflexion usually occurs 
in multiparas, in whom the uterine canal is larger and more patu- 
lous. The rectal symptoms are caused by pressure of the fundus 
against the rectum. 

Diagnosis. — Vaginal examination reveals the cervix low in 
the pelvis, with the os looking directly downward, while the 
fundus, as a firm, round body continuous from the cervix, is 
found in Douglas' pouch, the point of flexion being plainly felt as 
a more or less deep groove between the fundus and the cervix. 

Bi-manual examination will show the absence of the fundus 
from its normal position, and if the abdominal parietes are 
not too thick and firm we may be able to grasp the retroflexed 
organ between the finger in the vagina and the external hand. 
In this manner we can decide not only as to the position of 
the uterus, and the point of flexure, but also as to its size, form, 



RETROFLEXION OF THE UTERUS. 229 

consistency, sensitiveness, and mobility, and may thus be able to 
determine the probable difficulty of replacement. 

If not entirely satisfied, rectal examination will greatly aid 
in detecting these conditions. In determining the mobility of the 
organ, it is not only necessary to ascertain whether it is bound 
down by adhesions, but also whether, when the fundus is raised, 
the flexion disappears, or the uterus rotates as a whole, the flexion 
remaining. The introduction of the sound will show the direc- 
tion of the uterine canal, its depth, and the sensitiveness of the 
tissues. The sound must be curved to correspond with the degree 
of flexion supposed to be present, and introduced with its concav- 
ity backward. If retroflexion be present, it will not be necessary 
to rotate the sound in order to introduce it. We should also be 
certain that pregnancy does not exist before attempting to use the 
sound. 

An accumulation of feces in the rectum, an inflammatory 
exudation, a carcinomatous mass, hematocele behind the uterus, 
an enlarged and prolapsed ovary, or a fibroid in the posterior wall 
of the uterus, may be mistaken for the body of a retroflexed 
uterus; but the history of the case, together with the practice of 
the diagnostic methods above indicated, will probably remove all 
doubt. 

Prognosis. — This depends upon the mobility of the uterus 
and the possibility of replacement. The more recent the displace- 
ment, the more favorable are these conditions. According to 
Munde, "recent displacements of any variety are the only cases 
which offer a fair chance of complete recovery by any of the 
mechanical means at our disposal." 

According to Thomas, (1) the following conditions prevent a 
favorable prognosis. "1st. A cervico-vaginal junction so low 
as to give no post-cervical space for accommodation of a pessary; 
2d. The previous existence of peritonitis and fixation of the 
uterus; 3d. The existence on the posterior wall of a sensitive 
fibrous tumor."" 

Treatment. — This consists, first, in the replacement of the 
retroflexed organ, and second, its retention in the normal 
position. 

Replacement is usually a comparatively easy matter, pro- 
vided no adhesions exist. I always follow the plan advocated by 
Thomas (2), which is as follows: The patient being placed in the 
left lateral position, with the left arm drawn behind the body, the 
operator lubricates the ring and middle fingers of his right hand 
and passes them, with the palmar surfaces toward the posterior 

1) Op. Cit., p. 418. 

2) Op. Cit., p. 418. 



230 A TEXT BOOK OF GYNECOLOGY. 

vaginal wall, up to the fundus. He now stands behind the 
patient, his face looking toward her occiput, and the line of the 
anterior surface of his body being about on a level with one pass- 
ing through the woman's body at the base of the sacrum. Now 
bending forward, by the tips of the fingers he pushes the fundus 
upward, while by their bases he retracts the perineum, elevates 
the posterior vaginal wall, and admits air freely to the vagina. 
As the uterine body rises in the pelvis to a perpendicular, the flat 
surface of the finger-nails will rest against it. By these he makes 
pressure forward, that is, toward the pubes, and steadily forces 
the uterus into anteflexion. 

As Thomas says: "In very difficult cases the knee-chest 
position may be necessary, but it is not often called for." 

Some claim that the bi-manual method is a safer, more 
effective and permanent method of re-position. It is accomplished 
as follows: the patient being in the dorsal position, introduce 
two fingers of the left hand into the posterior fornix, and grad- 
ually elevate the fundus out of the hollow of the sacrum to the 
pelvic brim; then with the fingers of the right hand pressed down 
behind its posterior wall from the outside, and the finger of the 
left hand in the anterior fornix pressing against the cervix, the 
uterus is brought forward to an anteverted position. 

The sound is frequently used to replace a retroflexed uterus, 
but being used as a lever there is great danger of employing an 
undue amount of force, and thus causing serious injury to the 
mucous membrane. Under no circumstances should the sound, 
after being introduced, be simply rotated and the uterus lifted. It 
is very necessary to get a proper understanding as to how the 
sound is to be used in order to insure any degree of safety and 
efficiency. The method for so doing is so plainly described by 
Hart and Barbour that I will quote from them. (1) "The end of 
the sound should not be too much curved. If the flexion be 
pretty acute, so that the sound requires to be well curved to pass 
easily into the body of the uterus, we should first reduce the 
acuteness of the flexion by repeatedly passing in the sound more 
and more straightened. Having by this means partially converted 
the retroflexion into a retroversion, we proceed to re-position as 
follows: The sound lies as in position 1, in the figure (Fig. 158): 
the direction of the handle is backward, and the roughened face 
looks to the back; the intra-uterine portion also has the curve 
backward. Now lay hold of the handle loosely, rather allowing 
it to lie between the fingers than grasping it. Carry the handle 
upward toward the patient's right buttock (as she is on her left 
side), forward with a wide sweep, and downward again toward 

1) Op. Cit., p. 348. 



RETROVERSION OF THE UTERUS. 



231 



the couch, the shaft describing half a cone. The sound thus 
conies to lie in position 2, in the figure: the direction of the 
handle is forward, and the roughened face is now to the front; 
the intra-uterine portion of the sound has also rotated, so that the 
curve is now forward, but the uterus as a whole is still to the 
back (Fig. 158, 2, 2.) Now carry the handle of the sound gently 
and slowly backward, in a straight line toward the perineum. 
The sound now lies in position 3 : the roughened surface is to the 
front, but the handle is now directed backward; the fundus 
uteri is consequently in its normal position (Fig. 158, 3.) The 




Fig. 158.— Replacement of the Uterus with the Sound: 
cessive positions of the sound and of the uterus. 



3, the suc- 



reason for this manipulation is evident. If we rotated the handle 
of the sound forcibly round its long axis (bringing it at once from 
position 1 to 3), the intra-uterine portion would describe a wide 
curve within the uterine body and probably produce laceration of 
the mucous membrane. Before withdrawing the sound we make 
sure by external palpation that the fundus uteri is to the front, as 
the latter is more easily felt when stiffened by the sound." 



232 A TEXT-BOOK OF GYNECOLOGY. 

Sims', Elliott's or Molesworth's repositors may be employed 
instead of the sound, but with me their use has not proved satis- 
factory, nor do I think that any form of mechanism has been 
devised that is as useful or safe as the fingers in performing this 
operation. The uterus having been restored, the next thing is to 
hold it in position. This is best accomplished at first by the use 
of the glycerine plug, but it may be necessary, after all danger of 
inflammation from the efforts at replacement has passed, to adjust 
a suitable pessary. The glycerine plug should be placed in the 
anterior fornix, and not in the posterior, as is so often done, as the 
object is to produce pressure backward on the cervix, which 
tends to keep the fundus anteverted. Sometimes it is well to in- 
sert a second and smaller glycerine plug high up in the posterior 
fornix. 

Should it become necessary, as it most likely will, to resort 
to the use of a pessary, the selection and adjustment of the same 
will prove of great importance. It is not enough that a pessary 
merely stretch the vaginal walls, nor, on the other hand, will it 
answer to use a pessary that is too small, or whose uterine curve 
will allow the fundus to bend over it into an exaggerated retro- 
flexion. If there is a tendency to the latter, it is best overcome by 
using Thomas' retroflexion pessary (Fig. 159). 




Fig. 159.— Thomas' Retroflexion Pessary. 

This is a long, narrow instrument of extreme uterine curve, 
and with a bulbous upper extremity, which is sometimes made of 
soft rubber. The Hodge pessary (Fig. 133), or Emmett's (Fig. 
135), or Albert Smith's (Fig. 136) modifications of the same, are 
most effective, and most commonly used in retroflexion. Block 
tin pessaries are very convenient for those physicians who have 
sufficient mechanical ingenuity to mold them for the needs of each 
individual case. Dr. Thorburn says that "A skilled gynecolo- 
gist, with a few of these and a few soft watch-spring rings, can do 
infinitely more to relieve suffering than a mere pedant can with a 
large army of special pessaries." 

In using 1 the Hodge pessary it may be necessary to adjust it 
as an unyielding support, its lower end pressing quite firmly 



RETROFLEXION OF THE UTERUS. 



233 



against the anterior wall of the vagina, and its upper end pressed 
into the posterior fornix, not to hold up the fundus, as is usually 
supposed, but to make traction on the cervix and thus raise the 
fundus by leverage. According to Thorburn, ; ' The most valua- 
ble use of the Hodge is as a lever in itself. The lower end is free 
to ascend or descend, the center clings to the vaginal walls later- 
ally, but without undue pressure, and the upper end plays in the 
posterior vaginal fornix. In standing or in inspiration, the weight 
of the abdominal contents presses downward and backward, and 
causes the lower end of the pessary — the power — to descend. 
Through the fulcrum, somewhere toward the centre of the pes- 
sary, the weight, that is, the parts resting on the upper end, is 
raised, thus the posterior vaginal fornix is pushed upward, and 
the uterine leverage comes into play secondarily, not from a hard 
and fixed pressure, but from a lever spring, as elastic as that of 
the best carriages." 

In cases where the fundus is heavy and rebellious, Dr. 
Thomas recommends Cutter's pessary with the bulb (Fig. 160). 




Fig. 160.— Thomas' modification of Cutter's Pessary. 

He also advises, in those cases where the vagina unites itself to the 
cervix very low down, so u as to leave almost no post-cervical 
space," to use the intra-uterine stem, which is more fully men- 
tioned under anteflexion. 

As Dr. E. C. Dudley well remarks, (1) "It should be urged 
that no man can safely apply the pessary until he has fully appre- 
ciated its indications and contra-inclications. Few practitioners 
possess naturally the mechanical skill necessary to its proper 
adjustment. Of this thousands of unfortunate women bear wit- 
ness. Its dangers in inefficient hands are in striking contrast with 
its usefulness when judiciously employed." 

Dr. William Alexander, of Liverpool, has devised an ingen- 
ious operation for shortening the round ligaments as a means of 

1) Pepper's System of Medicine. Vol. VI, p. 173. 



234 A TEXT-BOOK OF GYNECOLOGY. 

curing posterior displacement of the uterus, which appears to have 
proved quite effective, and at the present time is coming into great 
favor with gynecologists. The operation is not exceptionally dif- 
ficult in the hands of a competent surgeon, and ' ' with reasonable 
care and precaution it cannot be considered dangerous." It con- 
sists in first making an incision one or two inches long on each 
side of the spine of the pubes, upward and outward. Then dis- 
secting down upon the external abdominal ring, the terminal 
fibres of the round ligaments as they appear are caught up by a 
blunt hook, and are drawn out until they are felt to hold the 
uterus sufficiently upward and forward. The shortened ligaments 
are then stretched to the pillars of the external rings, and the 
wounds are treated antiseptically. Usually a Hodge pessary is 
worn for some time after the operation (1). 

In all cases of retroflexion, as in other forms of displace- 
ment, it is important not to overlook the selection and administra- 
tion of the indicated remedy. 

8. Lateroflexion. 

Definition. — A displacement in which the uterus is bent 
upon itself laterally. 

Etiology. — This condition is most often congenital, but it 
may result from inflammation of the broad ligaments, or from pel- 




Fig. 161. — Thomas' Lateroflexion Pessary. 

vie exudations which pull the organ down and tend to fix it in the 
abnormal position. 

Symptoms.- — These are neither numerous nor characteristic. 
The flexion rarely becomes sufficient to cause obstruction of the 
uterine canal. 

Diagnosis. — Lateroflexion may be mistaken for the products 
of a pelvic cellulitis, or for a fibroid tumor, but the same princi- 
ples of diagnosis that have been mentioned under other varieties 
of displacement will serve here. » 

1) The most recent literature upon Alexander's operation is embraced in the December, 1887, 
number of the Annals of Gynecol, which contains a paper by Dr. J. H. Kellogg, of Battle 
Creek, Mich., detailing a report of 25 cases, and a full description of his method of operat- 
ing. Also abstracts of papers by Dr. Alexander and others which were read before the 9th 
International Medical Congress. 



LATEROFLEXION OF THE UTERUS. 235 

Treatment. — The same general principles of treatment 
should be followed as have elsewhere been given for other forms 
of flexion. Dr. Thomas says, (1), u Of all varieties of flexion, 
this is the most likely to require the use of the intra-uterine 
stem, for it is exceedingly difficult, I may say rarely possible, to 
overcome it by a vaginal instrument." 



1) Op. Cit., p. 422. 



CHAPTEK XXVI. 

9. INVERSION OF THE UTERUS. 

Definition. — Either a partial or complete turning inside out 
of the uterus, being compared by Thomas to 6 ' the bottom of a 
bag pushed through its mouth, so that the inner surface becomes 
the outer." The inner surface of the uterine canal projects 
through the dilated os into the vagina. 




Fig. 162. — Inversion of the uterus. 

Etiology. — According to Thomas, the production of inversion 
depends upon the presence of "two elements, 

1. Kelaxation and inertia of the uterine walls ; 

2. Downward traction or pressure." 

Inversion, if recent, usually occurs between the birth of the 
child and the delivery of the placenta, and is ordinarily supposed 
to be due to undue traction made upon the cord in the delivery of 
the latter, but Dr. Emmett thinks that u the injury is rarely due to 
this cause." Doubtless, however, this is sometimes a cause of in- 
version, as may also be the traction made in the sudden delivery of 
the child. Sudden muscular efforts, such as coughing or sneezing, 
or even a change of posture, may cause inversion when the uterus 
is in a very relaxed condition. Inversion, more rarely as a chronic 
condition, arises gradually from the traction of tumors attached 
to the uterine walls. According to Fritsch, (1) " Should there be 

1) Op. Cit., p. 222. 236 



INVERSION OF THE UTERUS. 



237 



a tumor exactly in the fundus, should the surrounding uterine tis- 
sue atrophy or undergo fatty degeneration, the tumor glides into 
the uterine cavity. Partly by the weight of the tumor, partly by 
the uterine contractions, the tumor — dragging the uterus along — 
is forced deeper. Finally the tumor passes through the os uteri, 
even in front of the vulva. Both benign and malignant tumors 
may lead to inversion." 

Pathology. — The anatomy of this condition is thus described 
by Schrceder: (1) "The uterus, turned inside out and lying within 
the vagina, presents a rounded, sometimes quite swollen body, 
with a somewhat puffy, reddish or bluish surface (the inflamed 




abed 

Fig. 163. — Stages and degrees of inversion of the uterus: a, chronic inver- 
sion as ordinarily encountered; 6, complete inversion of the cervix; 
c, partial or commencing inversion of the fundus; d, inversion com- 
mencing at the lower portion of the body. 

uterine mucous membrane). At its upper portion the tumor be- 
comes narrower, and forms a sort of pedicle lying between the lips 
of the os. These latter are distinctly to be felt, for a complete 
inversion of the organ seems to be impossible, the cervix, through 
which the inverted uterine body has descended, retaining, at least 
in part, its normal position. This is particularly true of the 
anterior lip. The cervix is completely involved in the inversion 
only when strong traction is made on the uterus ; perhaps, in some 
exceptional cases, also, through the weight of the tumor. After 
opening the abdominal cavity, on the dead subject, the site of the 
uterine body is seen to present a funnel-shaped depression, into 
which the tubes and ligaments of the uterus lead. In cases of 
long standing this funnel is very narrow (one-fifth of an inch at the 
outside), and the ovaries do not lie in it. At a later period the 
uterus may undergo material changes ; a process of involution 
takes place, and the mucous membrane becomes smooth — more like 
a serous surface." 

Symptoms. — Should inversion occur suddenly, as in the puer- 
perium, the patient will have considerable pain, vesical irritation 



1) Op. Cit., p. 216. 



238 A TEXT-BOOK OF GYNECOLOGY, 

and hemorrhage, accompanied by symptoms of shock and collapse 
out of all proportion to the loss of blood. This may endanger 
the life of the patient, but more often she rallies in spite of the 
hemorrhage, which continues in a mild degree, eventually produc- 
ing a profound anaemia. If the inversion is discovered and the 
uterus immediately replaced, with proper care no further trouble 
will ensue. If not discovered, septicaemia may result and cause a 
fatal termination, but more often the symptoms are not urgent, 
the character of the case remains undiscovered, and the patient 
gets up from her confinement feeling miserably, yet able to attend 
to her ordinary household cares. In some instances no symptoms 
are present, except, perhaps, a slight backache and leucorrhea, 
and the condition is discovered only by accident years after. 
More often, however, the hemorrhage is more or less constant; 
there is considerable difficulty in walking ; dragging pain in the 
back and loins; disturbances of the bladder and rectum; anaemia; 
nausea and vomiting, especially on assuming the upright posture ; 
palpitation and irregular action of the heart ; oedema of the face 
and lower extremities, and other symptoms which result from the 
loss of blood. Sometimes contraction of the cervix about the 
fundus produces gangrene, with its usual consequences. Should 
the inversion result from the traction of a fibroid tumor, the symp- 
toms come on gradually, but do not differ essentially from those 
already described. After a time the patient usually becomes bed- 
ridden, but this is not always the case. Emmett says (1) that 
' ' Instances have occurred where women have had the vitality to 
resist the consequences of inversion of the uterus for twenty or 
thirty years, until, at length, with the change of life, the drain has 
ceased." 

Diagnosis. — This can be determined only by a careful physi- 
cal examination, an anaesthetic being usually required. As the 
physical appearance of an inverted uterus is often strikingly simi- 
lar to that of a polypus, there might be some difficulty in differen- 
tiating between the two. This can usually be accomplished, 
however, by a careful conjoined manipulation. When the inver- 
sion is only partial, the diagnosis from a fibroid tumor is often 
more difficult. Thomas presents the following tables of differ- 
ential signs : — (2) 

If it be a Polypus. If it be Inversion. 

The probe will usually pass into The probe will be arrested at the 

the uterus; neck; 

Conjoined manipulation will re- Conjoined manipulation will re- 
veal the uterine body; veal a ring where the uterus should 



be ; 



1) Op. Cit., p. 407. 
ft) Op. Cit., p. 429. 



INVERSION OF THE UTERUS. 239 

Rectal examination will reveal the Rectal examination will not reveal 

uterus in situ; the uterus in situ; 

Recto-vesical exploration will re- Recto-vesical exploration will not 

veal the uterus; reveal the uterus; 

Acupuncture will give no pain. Acupuncture will give pain. 

If it be a Fibroid Growth. If it be Inversion. 

The probe will show increase of The probe will show diminution 

uterine cavity; of uterine cavity; 

Conjoined manipulation and Sim- Conjoined manipulation and Sim- 
on's method will reveal rotund body on's method will reveal small abdom- 
of uterus; inal ring; 

It will have come on very gradu- It will have occurred more sud- 

ally; denly; 

It will have no reference to partu- It usually follows parturition; 
rition; 

Acupuncture is painless. Acupuncture gives pain. 

The prognosis is unfavorable without operative interference. 
Even in old cases the prolonged hemorrhages may produce such 
profound anaemia and prostration as to lead to a fatal termination, 
and degeneration of the tumor may cause septicaemia. Reposition, 
however, may be accomplished in most cases, even in those of 
very long standing. Spontaneous reposition may take place, but 
is extremely rare. 

Treatment. — Treatment consists in the reposition of the in- 
verted uterus, or, if that fail, amputation of the organ, provided 
the symptoms are of sufficient gravity to warrant such an opera- 
tion, which would especially be the case if the uterus was gangren- 
ous, cancerous, or the seat of extensive ulcerations. 

Reposition. — This may be accomplished by the hand alone ; 
by the hand assisted by instruments ; or by a combination of 
these methods, with continuous slight elastic pressure. Efforts 
at reposition should be preceded for a few days by quiet rest in bed, 
and the frequent use of hot water injections for the purpose of 
reducing congestion and checking any hemorrhage that may be 
present. At the time of the operation the bowels and bladder 
should be emptied and the patient put under the influence of an 
anaesthetic and placed on her back upon a firm table. The left 
hand is then made to press firmly on the external abdominal walls, 
and the uterus being grasped between the fingers is steadily pushed 
upward through the cervix (Fig. 164). The first part of the 
operation is usually easily performed, but when the inverted fundus 
reaches the external os its progress Kecomes much more difficult. 
At this stage reposition is greatly aided by separating the fingers 
so as to distend the cervix as much as possible. Should this 
method fail, a colpeurynter filled with air or water may be placed in 
front of the uterus. This causes a softening of the tissues and 
more or less diminution in size of the organ, and slowly forces it 
through the cervix. Fritsch says that w k This method succeeds in 



240 



A TEXT-BOOK OF GYNECOLOGY. 



cases in which the employment of the greatest force and repeated 
attempts have led to nothing. The re-inversion ensues both 
slowly and imperceptibly, and without violent contractions of the 




Fig. 164. — Reposition of the inverted uterus with the hand alone (after 
Emmett). 

uterus." On the contrary, Emmett says: (1) "This plan is one 
scarcely worthy of reference in comparison with other means at 
command. It is one which almost always produces a great deal 
of disturbance, often causes cellulitis, and it is doubtful if the 
method is ever successful when employed alone. It has certainly 
proved in my experience a useless waste of time at least, if no 
other disadvantage followed its use." Should attempts at reposi- 
tion with the hand fail on account of the inability of the hand to 
keep up a continuous pressure, White's repositor may be used. 
This consists of a cup set on a curved iron rod with a spiral spring 
to make the pressure equal (Fig. 165). The operator steadies 
the cup against the fundus with the hand, and makes pressure 
against the spiral spring with his chest. 

Nceggerath's method consists in placing the index finger upon 
one horn of the uterus, the thumb upon the other, and so com- 
pressing as to invert one or both cornua. This method should only 
be employed for reducing the body after the neck has been replaced. 

Courty's method (2) consists in passing the index and middle 

1) Op. Cit., p. 433. 

2) Cincinnati Lancet and Observer, March, 1878. 



INVERSION OF THE UTERUS. 



241 



fingers of the right hand up the rectum, and with the left hand 
or a noose drawing down the uterus until these fingers get fairly 
above the cervix so as to press on the margins of the peritoneal 
depression; grasp the uterus now with the left hand, turning it so 




Fig. 165.— White's Repositor, with Elastic Spring Placed Against 
the Operator's Chest. While the right hand steadies cup and uterus, 
counter-pressure is made with the left, or better by an assistant. 

that the fundus is toward the symphysis and the cervix toward the 
sacrum; finally make pressure with the thumb and index finger in 




Fig. 166. — Tait's method of making 
bladder and rectum (Munde). 



counter-pressure with fingers in 



the angle of reflection against the two fingers in the rectum. Tait's 
method (1), (Fig. 166), consists in the introduction of the index 



1) Maladies de 1' Uterus, 1866. 



242 A TEXT-BOOK OF GYNECOLOGY. 

finger of the left hand into the bladder, and that of the right 
hand into the rectum. With these fingers catch and stretch the 
contracted cervical ring, while both thumbs are made to press the 
fundus upward and toward the cervix. By this method, in half 
an hour's time, Tait reduced a case of forty years' standing. 

These methods having failed, recourse may be had to a con- 
tinuous elastic pressure, which is produced by having a wooden 
cup set on a stem, the cup being made to embrace the fundus, pres- 
sure being obtained by means of four elastic bands, which pass, two 
in front and two behind, to a broad abdominal bandage (Fig. 
167). The cup should be lined with cotton soaked in carbolic 




Fig. 167. — Cup with stem and elastic bands, which are fixed to an abdo- 
minal belt, for gradual reduction of inversion (Thomas). 

oil, which should be renewed daily, and the vagina well washed 
out. Great care should be taken that the pressure is made in the 
proper direction and that the cup does not slip away from the in- 
verted fundus. Counter-pressure is made by a thick pad of cotton 
wadding placed directly over the fundus and held in position 
by attaching it to the abdominal bandage. Unless contra-indica- 
ted in some way this treatment should be employed for at least 
three or four weeks, if it does not sooner prove successful. 

Gentle manual treatment may in most cases be kept up for 
several hours if necessary, and should be persistently continued, 
unless contra-indicated, until it is reasonable to conclude that 
further efforts are useless. Numerous cases are reported where 
reposition has been effected after an inversion has lasted for many 
years. Emmett says, ' i as long as the etherization is well borne by 
the patient, no case must be despaired of in consequence of the 
apparent want of progress, for at any instant the reduction may 
be suddenly completed." 



INVERSION OF THE UTERUS. 



243 



In cases where the fundus has been pushed above the level of 
the external os, and further reduction seems impossible, Emmett 
(1) recommends denuding the inner edge of the cervix, and 




Fig. 168. — Emmett's method of retaining the partially re-inverted fundus 
by closing the os externum with sutures. The traction, produced in the 
direction of the arrows, favors re-inversion (Emmett). 

securing its surface with wire sutures, leaving an opening at 
each angle of the line for the free escape of the secretions and 
menstrual flow. The fundus being thus imprisoned in the cavity 
of the neck, tends to dilate the constricted os internum, after 
which the stitches may be removed and pressure again employed, 
and sometimes spontaneous reposition has followed without further 
manual treatment. In cases that prove irreducible, rather than 
perform amputation, Thomas recommends abdominal section over 
the cervical ring, dilatation with a steel instrument, made like a 
glove-stretcher, and reposition of the inverted uterus by any one 
of the methods mentioned, by the hand in the vagina. 

Amputation of the uterus has been performed in several dif- 
ferent ways, but it is a dangerous operation at best, and should 
never be resorted to except where the uterus is either cancerous, 
gangrenous, or extensively ulcerated. Dr. Emmett considers the 
operation so hazardous that he would not resort to it " under any 
circumstances." This being the case it is hardly worth while to 
occupy the space necessary to detail the different methods of oper- 
ation; suffice it to say that these consist either in the use of the 
ligature, the ecraseur, or the knife, or in a combination of the liga- 
ture with either the ecraseur or the knife. 



1) Op. Cit., p. 481. 



CHAPTER XXVII. 



FIBROID TUMORS OF THE UTERUS. 

Synonyms. — Myoma; Fibro-myoma ; Fibrous Tumors. 

Definition. — A localized hypertrophy, or partial hyperplasia 
within the uterine tissue. 

The origin of fibroid tumors is within the muscular structure, 
and they include both the fibrous and the connective tissues, hence 
the name, sometimes given, of fibro-myoma, which is probably the 
most accurate of the various designations ; yet, for the reason that 
fibrous tissue is usually predominant they are ordinarily known as 
fibroids, the term merely signifying that they resemble fibrous tis- 
sue, but not conveying the idea that they are of necessity exclu- 
sively fibrous in their structure. They may be limited to a small, 
localized mass within the uterine tissue, or may involve nearly the 
whole uterus, and they sometimes assume enormous proportions. 
Occasionally they undergo cystic degeneration, or, rather, an 
cedematous softening or liquefaction occurs in more or less of the 
growth, and the tumor is then termed a fibro-cyst. 

Pathology. — It might be inferred from the definition given 
that a fibroid tumor is a localized hypertrophy of uterine tissue, 
but, on the contrary, it is a distinct new growth developed within 
the uterine tissue. As Schrceder says, a fibroid does not ''repre- 
sent a mere diffuse enlargement of the uterus, but develops itself 
as a distinct round tumor, plainly separate from the parenchyma 
proper. 1 ' 

Fibroids are most often found in the posterior wall of the 
body of the uterus, though occasionally they are present in the 
anterior wall of the body, or in the cervix. Microscopically they 
consist of non-striped muscular fibre and fibrous tissue, which are 
irregularly distributed, and of varied proportions, usually the 
fibrous tissue being in excess, such tumors being well marked from 
the wall of the uterus, and of slow growth ; but occasionally the 
muscular tissue predominates, the tumor not being circumscribed, 
and the growth being rapid. The latter are true myoma, while 
the former are fibro-myoma. 

A myoma is of a pale flesh color and of soft consistency, while 
a fibro-myoma is pale, having less of the flesh color, is more dense 
and firm in its consistency, almost cartilaginous, thus appearing 
more like a foreign body embedded in the softer muscular tissue ;. 

244 



FIBROID TUMORS OF THE UTERUS. 245 

when cut, the surface presents a glistening, satin-like appearance, 
and is uneven or lobulated, the pressure of the fibrous bands throw- 
ing up ridges upon it. 

"As a rule, the uterus is hypertrophied, its walls are thick- 
ened ; sometimes, however, especially in subperitoneal fibroids, it 
may be thinned by reason of being drawn out in length ; and in 
old women it may be greatly atrophied. 

"Blood-vessels enter the tumor with the bands of connective 
tissue, though usually they are but few in number. It is exceed- 
ingly rare that any larger arteries dip into a fibroid. 

' ' The tumor apparently lies as a foreign body within the mus- 
cular substance of the uterus, inasmuch as it is separated by a 
capsule of loose connective tissue, from the parenchyma of the 
organ, and can readily be enucleated. Still, its development 
always begins in the uterine tissue itself, as a local hyperplasia, 
and it is not till later, when the well defined tumor grows by the 
multiplication of the elements belonging to it, that it pushes the 
muscular fibres of the uterus apart, lies between them, and is cap- 
able of being separated from them and turned out Nevertheless, 
a large fibroid is often continuously attached to the uterine paren- 
chyma by quite a broad base. 

"On the other hand, the tissue by which the tumor is attached 
to the uterus, and out of which it was, in fact, developed, readily 
atrophies; so that, then, the fibroid actually has no longer a con- 
tinuous connection with the parenchyma of the uterus. In the 
latter case, the blood-vessels become obliterated at the same time 
with the pedicle, so that scarcely any vessels enter the substance 
of such an isolated and embedded fibroid." (1). 

In exceptional cases, especially of the large interstitial variety, 
a cavernous structure is developed consisting of dilated blood- 
vessels. This form has been designated by Virchow as ' ' Myoma 
telangiectodes seu cavernosum. " 

Fibroid tumors are liable to undergo degeneration, either by 
softening, induration, calcification or suppuration. 

Softening may, according to Schrceder, be due to simple 
oedema, to fatty degeneration or to myxomatous degeneration. 

Only a very slight degree of oedema may be present, or it 
may occur to such a degree as to drive apart the connective tissue, 
and, filling the gaps thus left, give rise to distinct fluctuation, and 
constitute what are known as fibro-cystic tumors of the uterus. 
This fotfm of degeneration is most apt to occur in the submucous 
or interstitial varieties, but may take place in subperitoneal. 

The latter is sometimes called mucous degeneration, and con- 



1) Schrceder, Ziemssen, Vol. X., p, 224. 



246 A TEXT-BOOK OF GYNECOLOGY. 

sists in the deposit of intercellular mucus from the mucous tissues 
which exist within the tumor. 

Induration occurs in connection with fatty metamorphosis, 
the latter occurring in the muscular tissue, while the fibrous con- 
nective tissue becomes indurated and contracts, causing atrophy of 
the tumor. 

Calcification is liable to follow induration, a deposit of the 
salts of lime taking place, the whole mass becoming a ball of cal- 
careous matter. This form of degeneration occurs only in the 
subperitoneal and interstitial varieties. Sometimes the calcareous 
mass projects into the uterus, and is discharged per vaginam, con- 
stituting what the old writers described as uterine calculi. 

Suppuration may take place when the source of nourishment 
of the tumor has been cut off. This may occur in subperitoneal 
fibroids from twisting of the pedicle, or in connection with calci- 
fication, but it most often occurs in submucous tumors as a result 
of traumatic influences, especially from operative interference. In 
such cases either the whole of the tumor or pieces may be dis- 
charged per vaginam. These pieces are frequently gangrenous, 
and have an intensely disagreeable odor. Again, if subperitoneal, 
the tumor may perforate the abdominal walls; or, failing to do so, 
give rise to septic poisoning and fatal peritonitis. 

Cancerous or sarcomatous degeneration of a fibroid may take 
place, but this is of rare occurrence. Most often when the fibroid 
is found to be cancerous it will be discovered that the cancerous 
condition is secondary, having resulted as an extension of this 
disease from adjacent tissues, or from a distinct carcinoma exist- 
ing in the cervix. 

Varieties. — Klob divides fibroid tumors into two general 
classes, simple and compound. A simple fibroid is one in which 
there is but one tumor, a compound fibroid is where there are 
several small tumors united by loose connective tissue. A simple 
fibroid is usually spherical in form, smooth, and connected with 
the uterus by loose connective tissue. A compound fibroid is 
more vascular than the simple variety, and is nodulated, and not 
smooth. 

These varieties are clinically divided into subperitoneal, in- 
terstitial, and submucous, according to their locality. All fibroids 
are interstitial at the start. Should one form in the external lay- 
ers of the uterus it will naturally develop toward the peritoneal 
cavity, rather than into the resistant uterine tissue, and become 
subperitoneal, or subserous. Such a tumor may be sessile, and 
remain attached to the uterus by a broad base, sometimes assum- 
ing enormous proportions, or may form a pedicle, the length of 
which determines its mobility. Sometimes the pedicle is broken 



FIBROID TUMORS OF THE UTERUS 



247 



and the tumor rolls about in the abdominal cavity, or, adhesive 
inflammation being set up, becomes attached to some other of the 
abdominal viscera. Sometimes the pedicle becomes twisted, and 
oedema or gangrene follows with the usual consequences. 

Pediculated subperitoneal fibroids are usually compound, and 
are said to be especially prone to calcification. They often draw 
the uterus forcibly upward, causing elongation and increasing its 
depth, and sometimes also causing axial rotation with consequent 
hydrometra. Virchow says, that the body may even be torn from 




Fig. 169. — Typical varieties of fibro-myomata, semi -diagrammatic: 1, sub- 
serous; 2, submucous; 3, interstitial; 4, intra-uterine polypoid; 5, cer- 
vical. 

the cervix by the traction, and one such case is reported by 
Pinolini. 

Should the tumor begin to form near the middle of the uterine 
wall it will remain interstitial, though, when it becomes of great 
size, it may crowd the peritoneum, or even partially protrude 
within the uterus. Interstitial tumors may be simple, and reach 
enormous dimensions, but they are more often compound, there 
sometimes being as many as fifty present in one uterus. As to 
location, they are most frequently found in the posterior wall near 
the fundus, the opposite wall usually becoming quite thin, and the 
uterine cavity considerably distorted and enlarged. 

If the tumor begins to form within the inner layers of the 
uterine muscular tissue, it will develop toward the uterine cavity 
and become submucous. Submucous fibroids may remain 



248 A TEXT-BOOK OF GYNECOLOGY. 

attached by a broad base, but more often form a pedicle, and are 
then known as fibrous polypi, and constitute the most frequent 
and probably the most important variety of fibrous growths. They 
are at first round, • but afterward become pear-shaped or oval. 
Their presence in the uterine cavity may give rise to contractions 
of that organ and cause their extrusion into the vagina, their 
pedicle still remaining intact, or, their capsule may rupture and 
allow the tumor to be discharged in shreds. 

Fibrous polypi are softer than other fibroids, and more sub- 
ject to degeneration, though they never become calcified. 

Etiology. — Schrceder says: (1) " Nothing at all is known 
with regard to the causes which determine or favor the develop- 
ment of fibroids. Undoubtedly some local irritation is at the 
bottom of it, but as to the variety or the origin of this irritation, 
we are completely in the dark." 

This is the view entertained by most writers, yet Virchow 
and Winckel, both make great efforts to establish a cause for the 
development of fibroids. Fibroids occur mostly during the period 
of sexual activity, and in the married, especially those who 
have borne children, and they are said to occur most often in 
negresses; they are not traceable to previous pelvic inflammations 
or to traumatic influences, though these are mentioned as possible 
causes by Winckel. Thorburn says that fibroid tumors of the 
uterus are associated as accidental redundancies with those changes 
of tissue which are perpetually recurring from month to month in 
the uterus. 

Symptoms. — The symptoms of fibroid tumors depend very 
largely upon the complications that may exist. Subperitoneal and 
interstitial tumors give rise to but few subjective symptoms, fre- 
quently none at all, but the submucous variety is ordinarily accom- 
panied by many symptoms, some of which are rarely absent. 

The symptoms of fibroid tumors in general may be tabulated 
as follows : 

1. Menorrhagia or metrorrhagia ; 

2. Dysmenorrhea ; 

3. Leucorrhea ; 

4. Pain and discomfort throughout the pelvis ; 

5. Symptoms resulting from pressure of the tumor upon 
either the bladder, rectum, blood-vessels, nerves or ureters ; 

6. Sterility and abortion are frequent consequences. 
Subperitoneal fibroids, as a rule, give rise to no symptoms 

other than those usually found with all large abdominal tumors — 
a sense of weight and fullness, pain in the back, neuralgia of lower 
extremities, constipation, dysuria, bearing-down, impaired nutri- 

1) Op. Cit., p. 223. 



FIBROID TUMORS OF THE UTERUS. 249 

tion, dyspnoea, etc. All symptoms are usually aggravated during 
the menstrual period. Small subperitoneal fibroids give rise to 
little or no inconvenience. 

The irritation of the tumor may give rise to ascites, or to a 
circumscribed peritonitis with consequent adhesions, agglutina- 
tions and formation of false ligaments. Chronic metritis often 
occurs as a complication, presenting its usual variety of symptoms. 

Interstitial fibroids, if small, give rise to but few symptoms. 
They may cause dysmenorrhea by interfering with the expansion 
of the uterus during menstruation, and being usually situated in 
the upper part of the fundus, they may cause by their weight 
more or less anteflexion or anteversion, or occasionally retroflexion, 
with the usual symptoms consequent upon these displacements. 

When an interstitial fibroid becomes large it produces a 
train of symptoms caused chiefly by pressure — difficult breathing, 
paralytic weakness, oedema, constipation, hemorrhoids, dysuria, 
strangury, and sometimes retention of urine. If the tumor grows 
downward it may split the cervix, enter the vagina, become gan- 
grenous and produce septicaemia. 

Hemorrhage is the most important symptom in most cases. 
This arises from the great plethora of the tumor and uterus, as 
well as from the increased surface and hypertrophy of the endo- 
metrium, and consequent dilatation of the blood-vessels. The 
hemorrhages are sometimes very great, and fatal cases are reported, 
protracted menstruation, with occasional irregular hemorrhages 
supervening. Sometimes there may be no hemorrhages for months, 
when suddenly they reappear with alarming violence ; or, they 
may be present oftener, the patient scarcely recovering from the 
effects, of one hemorrhage before she is prostrated by another. 
Such patients are usually anaemic, but do not show the waxy pallor 
of countenance that is present when the hemorrhages result from 
carcinoma, Frequently these tumors grow to a very large size, 
sometimes assuming colossal proportions. Fig. 170, taken from 
Winckel, illustrates a fibro-cyst of the uterus, operated upon by 
Professor Severanu, which weighed 195 pounds, and contained 
17. 5 pounds of a coffee-ground sediment. The distance from the 
sternum to the symphysis over the tumor was three and one-half 
feet, and its circumference at the level of the umbilicus was six 
feet. 

Submucous fibroids give rise to the same class of symptoms 
-as are characteristic of pathological conditions of the endome- 
trium — hemorrhage, leucorrhea and uterine colic being the most 
important. Hemorrhage does not occur from the tumor, which is 
feebly vascular, but from the mucous membrane, and not that 
which covers the surface of the tumor, where it is usually very 



250 



A TEXT-BOOK OF GYNECOLOGY. 



thin, but from the hypertrophied mucous membrane of the uterine 
cavity, where the veins are large and distended, and their walls 
thin. The hemorrhages are very irregular as to time and quantity, 
sometimes being but a slight menorrhagia, at other times almost 
uninterrupted, and again they may occur at irregular intervals 
with great violence. 

The leucorrhea is usually profuse, more or less albuminous in 
character, and is caused by distension of the endometrium. The 




Fig. 170. — Enormous cystic myoma. 

uterine colic is usually present as a consequence of obstruction 
created by the presence of the tumor in the uterine cavity. The 
menstrual fluids being retained the uterus becomes dilated, and its 
contents are expelled by spasmodic labor-like pains. In sub- 
mucous "polypi," the congestion of the parts during menstruation 
may cause the polypus to swell, and thus produce uterine contrac- 



FIBROID TUMORS OF THE UTERUS. 251 

tions, which may force the polypus to extrude at the vulva, and 
thus bring about inversion of the uterus if the pedicle is strong, 
and absorption of septic material occur. If the contractions 
cease, the polypus may return to the uterine cavity, and be expelled 
again whenever the contractions are renewed. If it does not re- 
turn and the pedicle becomes compressed, gangrene and sloughing 
may occur, giving rise to septicaemia. If nourishment through the 
pedicle is not interfered with, the polypus may continue to grow in 
the vagina, or very rarely, the pedicle becoming more and more 
elongated, the tumor hangs outside the vagina, and constitutes 
what has been called a "myoma pendulum.'' 

The symptoms of a submucous polypus are essentially the 
same as those of a non-pediculated fibroid. They cause very con- 
siderable irritation of the mucous membrane, which often results 
in a profuse serous discharge, and this irritation may cause mucous 
polypi to spring up about the pedicle, and thus add to the source 
of irritation already existing. 



CHAPTER XXVIII. 



DIAGNOSIS AND PROGNOSIS OF FIBROID TUMORS. 

The physical signs of fibrous growths are usually so charac- 
teristic and striking that the diagnosis is comparatively easily 
made, but in some cases, especially in tumors of small size, the 
diagnosis is attended with great difficulty, and when inflammation 
is also present, it may prove impossible. 

Vaginal touch, abdominal palpation, and especially the bi- 
manual examination, are of great importance. To make the 
examination the patient should be placed upon her back, with the 
legs flexed. All constriction should be removed, and the bladder 
and rectum emptied. 

In considering the very important question of physical diag- 
nosis I shall, for the most part, follow Hart and Barbour (1) whose 
article on that subject I consider exceptionally intelligible and 
accurate. They say that " Physical diagnosis is best considered 
under two heads : (a) Of small fibroid tumors, up to the size of a 
walnut or egg ; (h) Of larger ones, which rise up as a distinct 
tumor into the abdomen." 

A— Of Small Fibroid Tumors. 

"1. Pediculated submucous fibroids should be easily recog- 
nized. When they are small and not projecting through the os, 
we have to dilate the cervix to ascertain their presence and attach- 
ment ; when larger and projecting into the vagina, they may read- 
ily be mistaken for inversion of the uterus. On sweeping the fin- 
ger round the base, we recognize the commencement of the cer- 
vical canal unless the polypus be adherent at its neck, leading to 
obliteration of the canal. Further, the bi-manual or rectal exami- 
nation shows the fundus uteri to be in its normal position. 

u 2. Small interstitial fibroids, when situated low down and 
causing bulging of one lip of the cervix, give rise to difficulty ; 
owing to the great enlargement of one lip, the os is displaced to the 
other side and its form altered to that of a mere slit, which easily 
escapes observation. Such cases have been occasionally mistaken, 
even by the most experienced, for inversion. The mistake is pre- 
vented by examination per rectum. Further, the sides and base 
of the tumor must be carefully scrutinized to discover the os ; 

1) Op. Cit., p. 392. 

252 



DIAGNOSIS OF FIBROID TUMORS. 253 

when this is found, the sound will show the position of the uterine 
cavity. 

"3. Interstitial fibroids placed high tip in the uterus, or 
small subserous ones with a broad base of attachment, often escape 
detection. To ascertain their presence we proceed as follows :: 
Pass the sound ; this defines the course of the uterine canal and 
the position of the fundus. Now make the bi-manual examination 
with the sound ; the finger in the anterior fornix detects the thick- 
ening of the anterior wall, produced by a small fibroid. Now 
steady the sound with the left hand, and pass the forefinger of the 
right hand into the rectum so as to feel the sound lying in the 
uterus. Should there be a fibroid in the posterior wall, the finger 
recognizes an unusual thickness of tissue between it and the sound. 
Carry the sound, firmly grasped by the left hand, toward the sym- 
physis, so as to bring the fundus better within reach of the rectal 
finger ; and, by moving it from side to side, ascertain whether the 
tumor is intimately connected with the uterus so that it moves 
along with it. From their being largely composed of fibrous tis- 
sue, these tumors are firmer than the uterine wall ; the localized 
hardness, therefore, helps us in recognizing them. 

"Small fibroid tumors require to be diagnosed from 
"Chronic metritis, 
' ' Early pregnancy, 
"Ante- and retro- flexion. 

' ' In chronic metritis the uterus is not globular but flat, and 
the enlargement is equable ; the uterine canal is patulous ; the os 
is everted, and shows catarrhal patches. We must remember that 
chronic metritis is occasionally present along with a fibroid tumor. 

"In early pref/7ia?icy the uterus is soft and elastic ; the cervix 
is generally, softened, while in fibroids it remains hard. Preg- 
nancy, however, may occur in a uterus which is already the seat 
of a fibroid tumor ; and in such a case the diagnosis becomes cer- 
tain only after the uterus is considerably enlarged. The possibil- 
ity of pregnancy must specially be kept in mind here, as we in- 
voluntarily think of using the sound to aid in detecting fibroids. 

" Anteflexion is closely simulated by a fibroid in the anterior 
wall ; a body is felt in the anterior fornix, continuous with it but 
separated by a groove. Similarly, a fibroid in the posterior wall 
has all the characters of the retroflexed fundus. Examination by 
the sound, and especially by the sound plus the bi-manual, clears 
up the case." 

B — Of Large Fibroid Tumors. 

" Palpation. — The tumor has a well-defined outline, and a 
firm, solid consistence. It is intimately connected with the uterus ;. 



254 A TEXT-BOOK OF GYNECOLOGY. 

this is best ascertained by laying hold of the cervix with the vol- 
sella, when the cervix will be found to move along with the abdom- 
inal tumor. Subserous fibroids have a certain range of free move- 
ment depending on the length of the pedicle. In soft fibroids, 
there may be intermittent contractions. Percussion. — The note is 
absolutely dull, unless intestines come between the tumor and the 
abdominal wall. Auscultation. — The uterine souffle is heard most 
distinctly at the sides, sometimes all over the tumor. As the 
uterine souffle simply means enlarged uterine arteries, there is no 
souffle when these are not enlarged ; hence it is absent in subserous 
fibroids with a small pedicle. Vaginal examination. — Should the 
tumor be large and lifting the uterus in the abdomen, the cervix 
will be high up ; or it may be displaced in various ways, according 
to the position of the tumor ; it has a firm consistence. Bi-manual 
examination. — With pediculat^d subserous fibroids, the uterus is 
felt distinct from the tumor ; with interstitial and submucous, we 
simply feel a large mass continuous with the cervix. Hie Sound. — 
This should not be used till all possibility of pregnancy has been 
excluded. In doubtful cases, we wait three or four months, till 
the positive signs indicative of pregnancy all have had time to 
develop. From the use of the sound we learn (1) the length, (2) 
the direction of the uterine cavity. The length of the cavity is 
always increased in submucous, and generally in interstitial, but 
not in subserous tumors ; it may measure six or eight inches. The 
direction of the canal is often tortuous in submucous tumors ; hence 
the passage of the sound is difficult, sometimes impossible. We 
feel that the sound goes so far and then catches on a hard projec- 
tion. In such a case a soft bougie is very useful, as its flexibility 
allows it to pass the obstruction. Usually the sound passes to 
only one side of the tumor ; sometimes we can sweep it more or 
less round the tumor, showing that it projects free into the uterine 
cavity. 

ki Large fibroid tumors require to be diagnosticated from 

' ' Advanced pregnancy, 

' ' Ovarian tumors, 

" Extra-uterine gestation, 

" Hematocele and inflammatory deposits. 
"In advanced pregnancy the uterus is of softer consistence and 
shows ballottement — the indication of a solid within a fluid ; 
further, we can feel the parts of the foetus. It becomes consider- 
ably harder under the hand, especially if we make the patient 
change her position ; this variation in consistence is a most valua- 
ble diagnostic, as it is rarely present in fibroid tumors. We hear 
the uterine souffle, and, unless the child be dead, we hear in addi- 
tion the fcetal heart ; the possibility of the child being dead should 



PROGNOSIS OF FIBROID TUMORS. 255 

always be kept in mind. On vaginal examination, there is discol- 
oration of the vaginal walls with free secretion ; the cervix is soft- 
ened. There is usually amenorrhea corresponding in duration to 
the size of the uterus. 

" Ovarian tumors are soft and elastic ; small ones may be 
firm. There is no uterine souffle. They only give rise to diffi- 
culty in diagnosis when they have become adherent to the uterus, 
and move along with it. It is sometimes impossible to diagnose 
between them and cystic fibroid tumors. 

' ' In hematocele and inflammatory deposits we have the history 
of the attack to guide us. It may be impossible to form a diag- 
nosis on first examination ; but after watching the case for a few 
weeks and noting any change in the deposit in addition to ascer- 
taining its precise situation, we can form a diagnosis. Pelvic 
peritonitis frequently occurs round a subperitoneal fibroid, or any 
fibroid producing pressure ; and in such a case it may be impossible 
to diagnose between the tumor and the effusion round it. Many 
cases reported of gradual absorption of a fibroid tumor, under 
treatment, were probably cases of mistaken inflammatory exuda- 
tion." 

Extra-uterine gestation presents great difficulty in diagnosis ; 
the tumor, however, is softer and more yielding, and of more 
rapid growth than a fibroid, and shows its cystic nature from the 
beginning, whereas a fibroid grows to considerable size before it 
becomes cystic. 

Prognosis. — Fibroid tumors rarely end fatally, yet they do 
in a sufficient number of cases to prevent the prognosis being 
altogether favorable. Very frequently the tumor remains during 
life, with but little change either in size or consistency, and caus- 
ing comparatively little inconvenience, though sometimes inter- 
fering with nutrition and impairing the vital powers. In other 
cases the patient may suffer considerably, and relief come only at 
the climacteric. In some instances a cure may occur spontaneously, 
either by fatty degeneration and absorption, or through arrest of 
growth by means of induration or calcification. In pedunculated 
submucous fibroids traction may cause the pedicle to break, and 
the tumor be spontaneously expelled. Occasionally from inter- 
ference with the nourishment of the tumor, either by twisting of 
the pedicle, or other causes, the tumor sloughs or becomes gan- 
grenous, and results in septicaemia or pyaemia, and death follows. 
In rare instances death has resulted from hemorrhage. 



CHAPTER XXIX. 



TREATMENT OF FIBROID TUMORS. 

The symptomatic treatment of fibroid tumors has not proved 
very satisfactory, so far as their radical cure is concerned; yet, as a 
means of palliation, medicines have frequently afforded compara- 
tively good results. I have now a case of interstitial fibroid in the 
posterior wall of the uterus, which has been in my hands nearly a 
year, and which has very perceptibly diminished in volume, and has 
become much less annoying to the patient, the hemorrhages having 
almost entirely ceased, under the continued use of Ustilago maidis. 
I have also frequently obtained temporary ameliorations of 
the symptoms produced by the pressure of a fibroid, with an appa- 
rent shrinking of the tumor, by the use of Secale cor. in a low 
attenuation. The latter drug, however, is usually given in hypo- 
dermic injections of from three to six drops of Squibb's solution 
two or three times per week. Simpson recommends the follow- 
ing formula : 

Ergotinoe 311 

Aquae 3vi 

Chloral hydrate 3ss. Mix. 

Twelve minims of the solution should be used at each injection. 

According to Winckel, (1) u The best article for use is the 
officinal preparation of the German Pharmacopoeia, 37 J grains 
being dissolved in 225 minims of distilled water and j- grain of 
salicylic acid being added, but no alcohol or glycerine employed. 
This solution will not decompose for years, and scarcely ever 
causes indurations or abscesses. I have treated a patient for more 
than ten years, who during this time has had 1500 injections 
given, and no abscess followed. 1 ' 

The preparation should be fresh, and the injection be made 
with great care as regards the admission of air or septic matter. 
The injection is best made in the abdomen or in the gluteal region, 
the point of the instrument being made to plunge much deeper 
into the muscle than when injecting morphine. Sometimes ergot- 
ism is induced by this method, and if so the injections should be 
discontinued at once. According to Fritsch, (2) u The theory of 
its action is, that the intact layers of uterine parenchyma contract;. 

1) Diseases of Women, p. 426. 

2) Diseases of Women, W. Wood & Co., p. 237. 

256 



TREATMENT OF FIBROID TUMORS. 257 

these contractions cause both shrinkage of the vessels with conse- 
quent defective nutrition of the myoma, and direct pressure upon 
the myoma. A proof of the correctness of this view is furnished 
by the not infrequent cases in which myomata necrose during the 
ergotin treatment, and the everyday observation that painful uter- 
ine contractions follow injections of ergotin. 

u Success is to be expected only when an intact muscular 
layer surrounds the myoma. Subperitoneal myomata with thin 
pedicles are not influenced by ergotin. Interstitial or submucous 
myomata experience both effects of ergotin, while polypi may be 
pressed out of the uterus by ergotin, but of course cannot be 
directly diminished. ,, 

The treatment should be continued for some time, at least for 
two or three months. It sometimes causes the entire disappear- 
ance of the tumor, but, if not, it frequently checks the disposition 
to hemorrhage, and ameliorates all the symptoms. 

The application of the internal remedy generally depends 
more upon the symptoms, which are a result of existing compli- 
cations, than upon those which are a direct result of the growth. 

For this reason we may be required to select our remedy from 
a large group of medicines which have been found most useful in 
such conditions, having in view solely the selection of the indi- 
cated remedy as accurately as possible. In addition to the Ustilago 
maidis and Secale cornutum already mentioned, we may have re- 
course to Belladonna, Sabiila, Viburnum op., Lachesis, Sepia, 
Calcarea carb., Ipecac, Crocus, Arsenicum, Cinchona, Phosphorus, 
Nitric acid, Sulphur, and many other remedies. 

Dr. Ludlam says (1) he could detail a number of cases in 
which the careful and persistent employment of Belladonna has 
removed a limited hypertrophy of the womb which, but for it, 
would undoubtedly have developed into a fibroid. It was given 
in the third decimal attenuation. He also speaks highly of the 
use of Lachesis, ''particularly when there is a defective involution 
of the womb." I would also suggest Lilium tig., in a similar 
class of cases. 

The same author, whose observations have been more exten- 
sive than those of any other gynecologist in our school of medi- 
cine, and whose experience is invaluable, says that he is 
"persuaded, as to the result of experience, that, in their early 
stages, these tumors are often curable by the use of internal rem- 
edies conjoined with very simple local means." As regards the 
local means to which he refers he is " in the habit of employing 
the cotton tampon saturated with pure glycerine, or with glycerine 
containing a few drops of the strong tincture of Calendula, of 

1) Diseases of Women, p. 1061. 



258 A TEXT-BOOK OF GYNECOLOGY. 

Hamamelis, Hydrastis, or of the same medicine that is being taken 
internally. This is an excellent adjuvant to the cure, and has the 
effect in many cases to avert the occurrence of frequent and 
dangerous hemorrhages. " 

The immediate control of hemorrhage is often an important 
matter. The patient should be placed in a recumbent posture, 
with the hips elevated, and treated with ice bags over the hypogas- 
trium and lumbar regions, or, as I very much prefer, receive con- 
tinuous vaginal injections of hot water at a temperature of about 
105 ° F. At the same time she may receive the indicated 
remedy — Belladonna, Sabina, Trillium, Ipecac, etc. 

Should these measures fail, resort may be had to tampons 
prepared from sponges, which are compressed and saturated with 
a solution of sulphate of alum. They may be prepared by taking 
a fine sponge, large enough to fill the vagina, passing a piece of 
string through the center to aid in its removal, and then, after dip- 
ping it in the solution, winding it with twine from one end to the 
other, compressing it into as small a space as possible. The twine 
should so compress the sponge as to make it assume an elongated 
form. It should then be laid aside and permitted to dry. Several 
sponges should be thus prepared. When necessary the twine may 
be unwound and the sponge introduced. Its size when in the dry 
condition will allow of an easy passage into the vagina, where the 
moisture will cause it to expand, and fill up and seal the vagina 
so as to absolutely check the discharge. If the attending physi- 
cian is present he may tampon the vagina with pellets of cotton 
secured by thread and moistened with a solution of alum. The 
inconvenience experienced from this plug will be more than coun- 
terbalanced by the saving of blood. 

Prof. By ford says (1) that this form of tampon has the ad- 
ditional advantage of being antiseptic. He has allowed it to remain 
for three days, and upon removing it satisfied himself that there 
was no decomposition of the blood or vaginal secretions. When 
the tampon is removed it will not be found difficult to wash out all 
the granular clots caused by its presence. It may be repeated as 
often as necessary, but usually, if allowed to remain forty-eight 
hours, the hemorrhage will not return. It may be said that for 
small losses this is unnecessary, but is convenient and harmless, 
and will answer the purpose. Dr. Winckel recommends that the 
tampon be made of salicylated cotton or borated lint. 

A sponge tent introduced into the cervix will not only serve 
as a tampon to arrest the hemorrhage, but will also stimulate the 
uterine fibres to contraction, and it is also claimed that by virtue 



1) Pepper's System of Medicine, Vol. IV, p. 228. 



TREATMENT OF FIBROID TUMORS. 259 

of the pressure created by the tent the vitality of the tumor is de- 
stroyed, its development arrested, and absorption brought about. 

In large tumors it is frequently necessary to relieve the pelvic 
viscera of their weight. The tumor should be elevated by placing 
the patient in the knee-elbow position and pushing the growth up- 
ward, after which it may be sustained by the use of a Hodge pes- 
sary, or sometimes by an abdominal bandage, which is better, if it 
can be made to answer the purpose. Sometimes the tumor is held 
down by peritonic adhesions and cannot be raised out of the pelvis. 

Surgical Treatment. — Should the measures already con- 
sidered fail to bring about improvement, it may prove necessary 
to resort to a surgical operation for the removal of the tumor. Yet 
it should be borne in mind that but comparatively few cases, not 
including submucous, have ever been cured by operative measures, 
and resort should not be had to these means unless the growth is 
either so located as to render its removal practicable and safe, or 
else it is threatening the patient's life. In case an operation is 
decided upon it should be the surgeon's object to adopt such a 
method as most nearly corresponds to those processes which nature 
has already adopted, or would most likely adopt, to accomplish a 
cure, according to the location and character of the growth. 

The surgical treatment of uterine tumors consists in their re- 
moval through the cervix and vagina, or through the abdominal 
walls. The first method is applicable in submucous growths, and 
the latter in subperitoneal. The interstitial variety have been re- 
moved in both ways, either by enucleation from within, or by 
laparotomy, the entire uterus with its new formations being removed. 

Removal through the vagina. — This may be accomplished 
either by excision, ecrasement, galvano-cautery wire, torsion, or 
enucleation. Whatever method is adopted the first step is to dilate 
the cervix with tents or dilators, or, if necessary, to divide it by 
making a bi-lateral incision with the scissors up to the vaginal 
junction, the os internum being divided with a tenotomy knife. 
Sometimes, this having been done, hemorrhage from the tumor 
ceases, and there is no occasion to carry the operation farther, or, 
the uterus may already be making efforts to expel the tumor, which 
is now more readily accomplished. 

Excision. — In case the growth is found to be a small sub- 
mucous fibroid it may be removed by the knife or by long handled 
scissors curved on the flat; or, if attached too high up to be reached 
in this manner, Aveling's polypotome (Fig. 171) may be required. 
If attached by a broad base, or if the pedicle cannot be reached, 
it may be necessary to cut the growth away in pieces. 

Ecrasement. — This may be accomplished by Chassaignac's 
chain ecraseur (Fig. 172), but I prefer the wire ecraseur, as it is 



260 



A TEXT-BOOK OF GYNECOLOGY. 



more easily managed and is not so injurious to the mucous mem- 
brane. In case the pedicle is thick and strong the chain ecraseur 
will be required. Ecrasement is safer than the knife, as it dimin- 
ishes the liability to hemorrhage, and its use is said to be less often 
followed by inflammation. 

Galvano-Cautery. — In most cases where ecrasement is pos- 
sible the galvano-cautery wire will answer a better purpose. It is- 



bo 



placed in position cold, then tightened sufficiently to slightly 
constrict the pedicle, and the current passed. The wire is then 
gradually tightened so as to burn through the tissues. 

Torsion. — In pediculated submucous fibroids I prefer torsion, 
or avulsion, to any of the methods previously mentioned. I con- 
sider it more simple, more expeditious and much safer in cases in 
which it is applicable. It is never followed by hemorrhage and 
there is much less danger of septicaemia, as no portion of the 



TREATMENT OF FIBROID TUMORS. 261 

tumor is left to slough. To operate by this method the tumor is 
seized as near its center as possible with a volsellum. It is then 
slowly and carefully twisted, and at the same time a slight but 




Fig. 173. — Volsellum Forceps. 



firm traction is made, which can be gently increased in force as 
the twisting progresses. 

Enucleation. — This method is applicable only to cases of 
sessile submucous growths, or to such interstitial growths as lie 
near the endometrium. It is at best a barbarous and dangerous 
proceeding, and should never be resorted to except as a last re- 
source in cases where less hazardous methods have failed to accom- 
plish the purpose, and the severity of the symptoms justifies a 
dangerous operation. 

The cervix having been dilated, the uterus is drawn down 
near the vulva with a volsellum, which is then firmly held by an 
assistant. It is sometimes only necessary to depress the uterus 
by firm pressure upon the abdomen, or both methods can be adopted 
at the same time. The operator then makes an incision about two 
inches in length across the dependent part of the tumor, with the 
scissors or a probe-pointed knife. This incision should be nearly 
a half-inch in depth, unless it is evident that the capsule is thin. 
Another incision is then made from the first incision, upward as 
high as the knife or scissors can be guarded with the finger. The 
fingers should then be inserted between the capsule and the tumor, 
and the former separated from the tumor as far as possible. When 
the fingers have accomplished all within their power the enuclea- 
tion is finished by means of an enucleator. The simplest enuclea- 
tor is that devised by Emmett (Fig. 174), which consists of a steel 




Fig. 174. — Emmett's Enucleator. 

instrument terminating in a serrated edge, which is to be put over 
the extremity of the index finger to take the place of the finger- 
nail in separating tissues. The finger is kept from slipping for- 
ward by the little hood just behind the saw catching over the nail. 
The extremity of the finger in front is left uncovered, so that the 
sense of touch is not interfered with, and the serrated tip can be 



262 A TEXT-BOOK OF GYNECOLOGY. 

directed with as much accuracy as if the finger-nail were used. 
This instrument, however, is not sufficient in some cases, where it 
may become necessary to use the spoon-saw devised by Thomas 
(Fig. 175). This consists of an elongated spoon with a serrated 




Fig. 175. — Thomas' Spoon Saw. 

edge. The tumor having been loosened, it is well seized with a 
strong pair of volsellum forceps, and attempts made to drag it 
out. If detachment is not complete, the efforts at separation should 
be renewed, after which firm traction should be made with slight 
efforts at torsion. After the tumor has been removed the uterus 
usually contracts and prevents hemorrhage, but for fear it may 
not do so, the operator should be provided with plenty of cotton 
saturated with sub-sulphate of iron, with which to plug the uterine 
cavity if necessary. Sometimes after the tumor has been successfully 
separated from its bed, it is found difficult to extract it on account 
of size. In such cases it may be necessary to still further enlarge 
the internal os, which may also be the case where the tumor has 
been separated from the uterus by the methods previously men- 
tioned. In the case of large tumors it may be required to use 
obstetric forceps for their extraction, or they may be divided with 
the knife or scissors, and removed piecemeal. 

Removal through the abdominal walls. Laparotomy. Gas- 
trotomy. — Subperitoneal tumors, and interstitial tumors lying in 
the outer uterine tissues, can be removed only through the abdom- 
inal walls. Fortunately this class of growths gives rise usually to 
so little disturbance that it is not often necessary to resort to so 
formidable an operation for their removal, yet there are cases 
where the life of the patient is threatened, and in such laparotomy 
is justifiable. Indeed this operation is now coming to be consid- 
ered but little graver in its character than ovariotomy, and is much 
more frequently resorted to than formerly. The first steps of the 
operation are identical with those of ovariotomy. The tumor 
having been reached, if it is fibrocystic, the fluid contents are 
evacuated as in ovariotomy. 

Subperitoneal tumors with a pedicle or a narrow base maybe 
removed, leaving the uterus intact. If the pedicle is not thicker 
than the thumb it should be perforated like an ovarian pedicle, 
tied with a double silk ligature, and then cut, leaving a sufficiently 
long stump, which is dropped back into the peritoneal cavity. 

Should the tumor be attached by a base too wide for ligature,, 
and requiring more or less enucleation, the treatment of the point 



TREATMENT OF FIBROID TUMORS. 2G3 

of implantation is important. According to Kaltenbach, (1) "We 
should then use elastic partial ligatures, or temporarily constrict 
the insertion of the tumor with a rubber tube, excise the tumor in 
a wedge-shape, and sew up the funnel-shaped wound. But as 
sutures, which do not encircle transversely the vessels emptying 
into the wound surface, are insufficient for complete haemastasis, 
Ave are generally compelled to ligate separately the vessels visible 
in the wound or to ligate the tissues. Hofmeier also calls atten- 
tion to the unusual difficulty of completely checking, by sutures, 
the hemorrhage from the surface of amputation in the uterus, and 
recommends that a few sutures be applied obliquely to the line of 
the wound, and that they be tied very firmly." 

Should the tumor prove to be interstitial, or subperitoneal 
with a very broad base, it will be necessary to extirpate the whole 
or a portion of the uterus with the new formations, including also 
the ovaries in case the patient has not passed the menopause, 
otherwise abdominal pregnancy might take place, or a fatal hema- 
tocele occur. Here the uterine stump constitutes the pedicle, 
which is usually treated by the extra-peritoneal method. Thomas 
recommends searing the stump with the actual cautery without 
any ligature, using the clamp to arrest hemorrhage during the 
amputation of the uterus, and while the pedicle is being seared. 
The clamp is in two separate portions ; the one half is placed 
below the neck of the tumor or uterus, and the other is then 
adapted to it and screwed down. To prevent retraction of the 
pedicle, before cauterization, it is transfixed above the clamp with 
long wire needles. After cauterization the clamp is loosened, but 
left in situ for fourteen days, so as to be screwed up should hem- 
orrhage occur. 

Hegar's extra-peritoneal method has afforded the best results, 
and is undoubtedly the most satisfactory of all the methods now 
in use. It consists in ' ' constriction of the uterine stump with 
elastic ligatures, exact closure of the abdominal cavity by stitch- 
ing the peritoneum round the stump, and antiseptic treatment of 
the latter with the cautery and chloride of zinc. " This method is 
fully described by Kaltenbach (2). The condition and relation of 
the ovaries and bladder having been ascertained, the cervix is en- 
circled by an elastic ligature, which prevents any further supply 
of blood to the uterus. If, on account of the large circumference 
of the cervix, or for any other reason, the elastic ligature is deemed 
insufficient, it may be replaced by two partial ligatures of a some- 
what less calibre. Kaltenbach' s larding pin is used to carry through 
the stump a double ligature, which is then divided and tied around 

1) Handbook of General and Operative Gynecology, Vol. II, W. Wood & Co., p. 57. 

2) Op. Cit., p. 60. 



264 A TEXT-BOOK OF GYNECOLOGY. 

each half. The uterus is then amputated from one and one-half 
to two inches above the ligatures. The next step consists in the 
accurate stitching of the peritoneum about the stump. A silk 
thread is passed into the peritoneum about one-half an inch below 
the posterior surface of the stump behind the elastic ligatures, and 
then brought out at a corresponding part of the opposite edge of the 
peritoneum. On tying the thread the parietal peritoneum is closely 
applied to the serous covering of the stump. The peritoneum is 
stitched in the same way on the anterior, and, if necessary, on the 
lateral surfaces of the stump. Above the stump (which is covered 
with peritoneum), and in the direction toward the umbilicus, are 
inserted three or four sutures, which include the peritoneum alone ; 
then the abdominal wound is closed in the ordinary manner by 
alternate deep and superficial sutures. 

The projecting end of the stump is thoroughly cauterized ; 
the raw surfaces round it are painted with 3-10 per cent, solution 
of chloride of zinc, and cotton wadding, which has been soaked in 
a two per cent, solution of the chloride and then thoroughly dried, 
is packed around the stump. Finally, the end of the stump alone 
is touched with a 100 per cent, solution. The whole is covered 
with protective silk and carbolized wool, and the antiseptic dress- 
ing laid on in such a manner that the stump and vicinity may be 
inspected at any time, without disturbing the patient, by merely 
throwing back the lower border of the bandage. 

The antiseptic dressing about the stump is changed frequently 
according to the amount of discharge, and the pedicle is gradually 
pared away from day to day with scissors to decrease its size, and 
to prevent pus from burrowing, and the elastic ligature is cut off 
about the tenth day. 

The complications mostly to be feared are : (1) Primary or 
secondary shock or collapse ; (2) hemorrhage ; (3) peritonitis ; (4.) 
septicaemia. Efforts should be made to avert these accidents in 
accordance with rules elsewhere considered, or, having already 
occurred, they should be treated in the usual manner. 



CHAPTER XXX. • 



TREATMENT OF FIBROID TUMORS BY ELECTRICITY. 

For several years past electricity has been used in the treat- 
ment of fibroid tumors with comparatively negative results. 

Kimball and Cutter apply it in the following manner : The 
two electrodes, needles about eight inches long, are inserted into 
the tumor, and the current allowed to flow for about fifteen minutes. 
An anaesthetic is unnecessary. The battery consists of eight zinc- 
carbon elements, from six to ten inches long. The operation, 
repeated from one to nineteen times, is said to have stopped the 
growth in twenty-six cases, but was without effect in ten ; the 
tumor was reduced in twenty-three, in thirteen not reduced. Two 
cases terminated fatally from peritonitis, and the tumor is said to 
have completely disappeared in three instances. 

Beard and Rockwell, and others, have adopted about the same 
method of treatment with similar results. I have also employed 
the constant current in several cases with the apparent effect in 
most instances of holding the growth in check, but nothing more. 
This having been the usual experience of gynecologists, it is not 
surprising that the method of treatment has received so little 
support from the profession, its practice being confined almost 
exclusively to enthusiastic specialists. 

This subject has recently been more favorably brought to the 
attention of the profession by a paper by Dr. Apostoli, read at the 
meeting of the British Medical Association at Dublin, in August, 
1887. 

Dr. Apostoli defines his treatment as "a galvano-chemical 
cauterization of the uterus, vaginal, intra-uterine or parenchy- 
matous, and always monopolar." 

It is conducted as follows: u The patient being in the lithotomy 
position, a piece of good plastic clay, about ten inches by five, 
is then placed upon the abdominal parietes, and in tSis is embedded 
a flat metal plate, about five inches by three, to which metal plate 
•one of the ends from the battery is attached. A platinum sound, 
sharp-pointed, is then introduced into the uterus per vaginam and 
made to penetrate the tumor to a slight depth. The current can 
now be passed between the metal plate via the clay on the body, 
and the platinum sound or needle in the uterus. The strength of 

265 



266 A TEXT-BOOK OF GYNECOLOGY. 

the current is accurately gauged by an electrometer, which measures 
up to 250 milliampereSj" 

In the paper above referred to, Dr. Apostoli elucidates his 
plan of treatment and makes so plain his claims for its superiority 
over all other methods that I shall quote his own language, it being 
so concise that any attempt to alter it or to give a synopsis would 
fail to give the student a proper understanding of this recent and 
most promising addition to the therapeutic literature of fibroid 
tumors. 

Dr. Apostoli points out a very evident fact, ' ' that his pre- 
decessors in the electrical cure of fibromes have employed the 
current in a vague and uncertain manner, without dosage by means 
of a galvanometer, in insufficient amount, and often in a dangerous 
manner, the galvano-puncture being made above the pubes and 
through the abdominal integument." He then continues : 

' 4 1 have supplanted the old way of operating by a new method, 
which is : 

" 1. Precise, by the introduction of new galvanometers of 
intensity — exact counters and measures of the electric current. It 
is in this way only that we can estimate the value of the fluid 
passed and utilized through the uterine tissues. 

" 2. Energetic, by an absolutely novel service of high intens- 
ities of current, which I have progressively carried, according to 
the necessities of my cases, from 50 to 150 and 250 milliamperes. 

"3. Tolerable, in spite of the enormity of these doses, in conse- 
quence of the introduction of a new form of electrode, the wetted 
clay, which renders the cutaneous pole innocuous and permits us 
to transmit through it easily and without injury a current of signal 
medical intensity. 

'■< 4. Better localized, by a direct application of the active 
pole, by way of the vagina, to the uterus, either in its cavity, or 
in the substance of the fibroid deposit. 

"5. Thoroughly under control, by the exclusive choice of 
the unipolar method. In fact, I apply to the diseased uterus a 
continuous galvanic current of an intensity and duration sufficient 
to produce the therapeutic effect required. Now this application, 
which is generally inaccurately described as electrolytic, ought to 
be defined as a gaivano-chemical cauterization, that is to say, a 
cauterization purely chemical. In the course of this current through 
the tissues there are two successive and distinctive effects developed: 
(a) The tangible effect at the points of entry and exit of the 
current, which according to the dose and duration, will be a chem- 
ical cauterization more or less severe (but not thermic), variable 
in conformity with the pole, and different in its character as the 
positive pole and the negative pole. This polar action, at the will 



TREATMENT OF FIBROIDS BY ELECTRICITY. 267 

of the operator, may be either monopolar or bipolar, (b) The 
effect resulting from the circulation of the current from one pole 
to the other, which is therefore called interpolar action. This 
action follows every electrical application and sets up a subsequent 
process of disintegration, proportionately wide and lasting, of the 
morbid products through which it is made to pass. 

"In serving myself to tEe utmost of the polar and interpolar 
effects of the electric current for the treatment of fibroraes, I adopt 
always a galvano-caustic, intra-uterine and monopolar. I thus only 
use directly one active pole, closing the circuit outside the abdomen 
by a second pole, made as nearly as possible inert. At the same 
time, I reckon upon the interpolar effects of the current, as it 
necessarily finds its way through the entire uterine substance, from 
the internal pole to the external or cutaneous pole. This, as I 
have explained elsewhere, is the principal reason why I do not 
place the two poles in the vagina, and why I advocate the method 
known as uterine monopolar. 

"6. More scientifically exact ; from the due appreciation of 
the topical effects of the two poles, and the precise chemical and 
anatomical indications peculiar to each of them. 

"I have been able to demonstrate, in the clearest manner, 
that we have in our hands a double-edged agent, that we can make 
use of it at discretion, to afford its local effects quite different. 
On the one side is an hsemastatic, more or less rapid in its action, 
and either direct and immediate, or secondary and remote. I 
allude to the positive pole, with which we can arrest hemorrhage, 
either instantly, if the cavity of the uterus be of normal dimen- 
sions, if the action be relatively intense, and if the hemorrhage be 
not excessive ; or more deliberately and gradually, after several 
successive operations, by the formation of contractile cicatrices. 
The various graduations of the narrowing of the uterine canal are 
the plain evidence of this secondary and prolonged effect of positive 
cauterization. 

"The positive pole will therefore be the ' medicament par ex- 
cellence ' in cases of bleeding or hemorrhagic fibromes. 

"On the other hand, with the negative pole we obtain a state 
of temporary congestion, without direct haemastatic effect. The 
interstitial circulation of the uterus, thus momentarily stimulated, 
will be hurried on, and a regression of the non-hemorrhagic fibromes 
is the consequence, either of this state of congestion, or of the 
supplementary artificial and salutary hemorrhages which take place. 
The negative pole will therefore be found to render invaluable 
benefit (though with the positive pole it is possible to arrive at the 
same point by a way more indirect and tedious), in those cases of 
fibroids accompanied with amenorrhea and dysmenorrhea, which 



268 A TEXT-BOOK OF GYNECOLOGY. 

are only too often the despair both of patients and doctors without 
such means at command. 

"Looking therefore at the difficulties and dangers of ab- 
dominal surgery, and at the avowed impotency of the greater part 
of medication in cases of fibromes, I do not hesitate to assert for 
my method of treating them a precedence on the following grounds: 

1. "It is easy of application; since it only requires an 
elementary acquaintance with the principles and practice of electro 
therapeutics ; it being, however, unconditionally understood that 
a profound knowledge of gynecological science must be the indis- 
pensable prelude to any attempts. 

2. " It is simple; for it is ordinarily nothing more than a 
skillful, uterine, therapeutical soundage. This is only what may 
be expected of every surgeon provided with a good galvanometer 
of intensity, some sort of battery capable of yielding an adequate 
current of electricity, an inoffensive cutaneous electrode in wet 
potter's earth, an inattackable intra-uterine electrode in platinum, 
and a steel trocar for the galvano-punctures. 

3. " The current is mathematically dosable ; so that every 
operator can carry on the treatment under the same conditions, 
and adjust the force of his remedy to the nature of the effects he 
has to obtain. 

4. ' ' The seat of operation is optional ; for the surgeon has 
the power of limiting and defining the point of entrance of the 
current, making it either the mucous membrane or the tissue of 
the organ. 

5. "It is of easy control; and only utilizes an amount of 
force, which should cause neither shock nor suffering, and ought 
never to be put to use but in progressive and adjusted doses. 

6. "It is antiseptic in itself, by virtue of the high cauteriza- 
tion of the active pole. 

7. "It is for the most part easily supported; anaesthetics 
being required only for certain cases of galvano-puncture. 

8. " It does not impose upon the patient any forced seclu- 
sion ; and mostly admits of their continuing the usual habits of 
life, and even of doing hard work in the intervals between the 
operations. 

9. "But over and above all these considerations, there is one 
dominant point to be advanced, which alone is of weight enough 
to turn the scale in favor of the electrical treatment. The simple 
chemical cauterization, for which you may find the equivalent in 
the laboratory of the chemist, or in the actual cautery, is not the 
only matter we have to take account of. This chemical cauteriza- 
tion — so-called polar — is only the first part of the therapeutical 
scene which gradually unfolds itself. 



TREATMENT OF FIBROIDS BY ELECTRICITY. 269 

"The electrical current — the power we wield, and the accom- 
paniment of every vital manifestation, in its course through the 
tissues acts prolongedly and profoundly on every molecule, and 
thus causes ulterior changes in the tumor structure, which may 
well astonish both by their extent, safety, and certainty." Dr. 
Apostoli then mentions the difficult and dangerous character of the 
operation of galvanic-puncture in incautious hands, and gives the 
following summary of directions and precautions, which he says 
should be r^idly observed : 

1. "Absolute and regular antiseptic irrigation of the 
vagina, before and after each operation. 

2. "Use as the puncturing instrument a small steel trocar 
or needle, and let the punctures be shallow, that is, not deeper 
than from one to two centimetres. 

3. "Make the punctures on the most prominent part of the 
fibroid ; whenever possible, in the posterior cul-de-sac. 

4. ' ' Make the punctures without speculum. Slide the trocar 
through the celluloid sheath which protects the vagina, after 
having examined and chosen by touch the point where the punc- 
ture is to be made. 

5. "Take the precaution of ascertaining the seat of any 
pulsation, so as to avoid wounding an important vessel. 

6. "In case of any unusual hemorrhage, immediately dilate 
the vagina with an expanding speculum, and if necessary put on 
pressure forceps to the bleeding point." 

The anatomical and clinical results to be anticipated are as 
follows : 

(A) "As regards the material changes, we may affirm that 
every fibroid tumor submitted to this treatment, sometimes after 
so short a time as one month, but certainly when the treatment is 
fully carried out, will undergo a manifest reduction appreciable by 
the touch, and demonstrable by internal measurement. The fur- 
ther diminution of the tumor which continues for some months, 
varying in amount from a fifth to one-half of the original volume, 
is generally associated with a coincident and equal accumulation 
of subcutaneous adipose tissue on the abdominal walls. 

"The regression of the tumor is not only apparent during 
the time of active treatment, but goes on continuously after it has 
been suspended, and is the persistent proof of the enduring influ- 
ence of the electrical operations. 

"The liberation of the tumor from its local attachments takes 
place simultaneously with its decrease of bulk. The tumor, which 
at the commencement of the treatment was immovable, can pro- 
gressively be made more and more to change its position, as the 
absorption of the enveloping tissues deposited around it advances. 



270 A TEXT-BOOK OF GYNECOLOGY. 

"Another phenomenon is observed in connection with the 
regression of the tumor. It not only contracts on itself, but it 
shows a tendency to separate itself from the uterus, to become 
more distinctly subperitoneal, to detach its mass as it were from its 
setting in the uterine wall, and to remodel itself into a peduncu- 
lated form. 

(B) ' ' Clinically, the results are less striking. Perhaps they 
are even more so as they are not only matter of proof by the 
examination of the surgeon, but the patient herself js the living 
exhibition of them. We may generalize the extent and import- 
ance of these results by saying, that ninety-five times out of a 
hundred they comprise the suppression of all the miseries consti- 
tuting the fibroidal symptomatology, which may be thus categori- 
cally enumerated — hemorrhages, the troubles of menstruation, 
dysmenorrhea, amenorrhea, nervous disturbances, the direct pains 
in the growth itself, and from mechanical pressure, and the har- 
assing series of reflex actions. 

4 ' In a word, the assertion may be safely advanced that, 
though our therapeutical resources carry us only so far as the 
sensible reduction of fibroid tumors, and not to their total absorp- 
tion, we may, with regard to the symptoms, certainly anticipate 
their complete removal, and the establishment of a state of health 
equivalent to a true resurrection. I am justified in saying that the 
greater part of women who have persisted in the necessary treat- 
ment, not only were cured but remain well. 

' ' I use the expression, the greater part, because there is no 
such thing as human infallibility, especially in medicine. I ack- 
nowledge having been sometimes unsuccessful, and so instructive 
are my failures, that I shall recount them at length in a work now 
preparing. It will be seen that they were cases in which there 
was no possibility of satisfactory treatment, owing to an appar- 
ently absolute intolerance of high intensities of current. I now 
see that I was wrong in retreating before this supposed intoler- 
ance. Among them were three cases of fibrome with ascites, and 
I regret now that, with the aid of anaesthetics, I did not persist in 
going to the limit of my power. I have also met with the same 
intolerance in some hysterical subjects, in case of very irritable 
uterus, and in others of peri-uterine and intestinal phlegmasia. 
Now, with my present experience, I should not hesitate to operate 
to the fullest extent with the patient under chloroform. There 
remains yet the obscure question as to the cause of cystic fibromes, 
and tumors with a tendency to malignant degeneration, where 
there is often an accompanying fearful and irrepressible hy- 
drorrhea. I have recorded three such instances, and in them intra- 
uterine galvano-cauterization generally proves useless. Something 



TREATMENT OF FIBROIDS BY ELECTRICITY. 271 

more is demanded, and we must seek in galvano-punctures means 
of denutritive action more powerful and more efficacious. 

"Finally, I may lay down the following proposition. No 
operator should admit the failure of intra-uterine galvano-cauteri- 
zation before having had recourse to the galvano-punctures, which 
he must enforce either with or without anaesthetics." 

Dr. Apostoli confesses to having excited " or aggravated in 
the course of five years, ten peri-uterine phlegmonous inflamma- 
tions, 1 ' but he says that "these must be attributed to blunders in 
carrying out the treatment.' 1 

' L These errors of practice happened during the early days of 
my work, and were either (a) a negligence of antiseptic measures, 
which were either omitted altogether or done imperfectly ; or (b) 
the too violent, or too intense, use of the negative pole, in cases 
of subacute peri-uterine inflammations. 

"The fact is, that the negative pole, having a strong power of 
producing congestion, is a dangerous weapon, which at the begin- 
ning of any treatment must be brought to bear with great prudence 
and reserve, if one would avoid overshooting the mark for which 
it is intended. To lay before you the facts of these accidents will 
serve the double purpose of warning you of what may befall you, 
and of preventing you from falling into similar errors. My caution 
is, that whenever the negative pole is put to use, and there is any 
trace of peri-uterine inflammation present, you must not only 
redouble your antiseptic needfulness, but your operative proceed- 
ings must be carried on with deliberate carefulness. You must 
feel your way, testing the susceptibility you have to work upon 
by two or three preliminary operations, in which you give doses 
so feeble that they only serve to enlighten you, and to habituate 
the patient, so as to lead on safely to the use of higher intensities. 

1 ' But when I tell you that this operative gynecology, as I 
have to practice it, is carried on in such exceptional circumstances 
that no one else has ventured to encounter them, and upon a class 
of women who are obliged to walk home shortly after they get up 
from the couch, who seldom take the necessary rest in bed, who 
are in no way under my surveillance, and whose poverty forces 
them in some fashion to get through all the ordinary duties of 
life, you will be curious to know, and you will ask of me, what is 
the explanation of the illusive mystery. All that I can say is — it 
appears to me that the intra-uterine current, at the high propor- 
tions I trust to, seems to have in itself some special antiseptic and 
atrophic property. 

"Among the patients who had not the will to let me finish what 
I had begun, and whose impatience led them voluntarily to seek 
the removal of the tumors by excision, seven put themselves into 



272 A TEXT BOOK OF GYNECOLOGY. 

the hands of six of our most eminent surgeons, and not one of the 
seven recovered from the operation. Commentary on this would 
be superfluous." 

When we compare these results with those of modern sur- 
gery under the most favorable circumstances, we cannot resist the 
conclusion that Dr. Apostolus method promises much in the treat- 
ment of fibroid tumors, and deserves careful investigation and 
trial. 

Dr. Stevenson, of St. Bartholomew's Hospital, London, in 
commenting on this treatment, says, (1) "The great danger insep- 
arable from abdominal section, and the uselessness of all medical 
treatment for the removal of uterine fibroids, makes this mode of 
treatment by electrolysis the more acceptable and of greater 
importance. Enucleation is often impracticable, and is never 
unattended with danger. In electrolysis we have a means of re- 
lief, the application of which is not difficult to those who understand 
the medical and surgical uses of electricity. It is not unduly 
painful. It is, if properly applied, practically free from danger. 
If the tumor is not much reduced in size, the distressing symptoms 
are almost invariably relieved and the patient's general health im- 
proved ; and she is not in a worse condition for more heroic 
measures, should they be deemed advisable, than before the appli- 
cation of electricity . " 

Dr. Stevenson uses electrodes which he claims possess some 
advantages over those used by Dr. Apostoli. "They consist of a 
copper wire, insulated by gum elastic, to the end of which is 
welded a piece of platinum of about an inch in length, and of the 
size of a No. 6 English catheter. The expense is very much less, 
on account of the smaller amount of platinum used in their com- 
position. The flexibility is an advantage, as it enables them to be 
passed into the uterine cavity through the cervical canal in many 
cases when it would be impossible to do so with the rigid electrode 
used by Dr. Apostoli. When a fibroid tumor is present the uterus 
is often tilted in one direction or another, so that the opening and 
course of the cervical canal are very much displaced from their 
normal position. And, again, with the celluloid or vulcanite sheath 
used by Dr. Apostoli, it is almost impossible to shield that part of 
the platinum rod which is in contact with the cervical canal and 
os uteri. With the electrodes I use it is quite easy to get the 
unprotected end of the platinum well within the uterine cavity, 
the gum elastic part of the stem only being in the cervical canal." 



1) British Medical Journal, Oct. 1887, p. 702. 



CHAPTER XXXI. 



MUCOUS POLYPI OF THE UTERUS 



Definition. — A pediculated uterine tumor covered with 
mucous membrane and composed of glandular and connective 
tissue. 

Pathology. — These tumors may either consist of connective 
tissue in a state of hypertrophy or hypergenesis, or of Xabothian 
or other uterine glands in a state of dilatation. Frequently a 
mucous polypus presents both the dilated glands, and the hyper- 
trophied connective tissue, and also epithelium and muscular fibre, 
such being designated as fibro-cellular polypi. Mucous polypi 
have their origin from the mucous membrane of the uterus, most 




Fig. 176. — Group of mucous polypi growing in the cervix uteri. 

frequently from the cervix. They usually have a flattened, pear- 
shaped form, and vary from the size of a pea to that of a hen's 

273 



274 



A TEXT-BOOK OF GYNECOLOGY. 



egg, though rarely exceeding that of an almond. They are of a 
soft, pulpy consistence, very vascular, and of a bright red color. 
The pedicle is usually long and slender, the polypus sometimes 
hanging outside the vulva. 

Where the polypus is made up of dilated glands or follicles, 
individual follicles may separate to form a secondary polypus on 
the original growth, the whole being bound together by connec- 
tive tissue, and giving rise to a mass resembling more or less a 
bunch of grapes (Fig. 177). Such a case is reported by Thomas, (1) 




Fig. 177. — Glandular polypus. 
' ' where the growth measured in length four and one-half inches, and 
in its longest diameter two and seven-eighths inches. It filled the 
vagina completely, grew from the inner wall and lip of the cervix, 
caused no symptom except leucorrhea and pelvic neuralgia, and 
was not suspected until difficulty in sexual intercourse caused the 
patient to apply for examination." 

Etiology. — The chief cause of mucous polypi is chronic cer- 
vical endometritis, which causes hypertrophy of the connective 
tissue and swelling of the follicles, giving rise to a small elevation 
on the surface, the base of which becomes gradually smaller until 

1) Op. Cit., p. 532. 



MUCOUS POLYPI OF THE UTERUS. 275 

only a slender pedicle remains. Thus, according to Thomas, ' 'any 
influence tending to keep up uterine congestion will predispose to 
hypergenesis of the elements of the mucous membrane. 1 ' 

Symptoms. — The most important symptom is hemorrhage, 
sometimes occurring only as a profuse menstruation, but more 
often, later, as an irregular metrorrhagia of more or less violence. 
Should the polypus hang free in the vagina so as not to be a source 
of irritation in the cervix, there is no hemorrhage. 

Leucorrhea is present as a result of the endometritis. Pain 
in the back and loins is usually more or less severe, and sometimes 
the polypus, obstructing the menstrual flow, gives rise to the char- 
acteristic pains of obstructive dysmenorrhea. Similar pains may 
also occur from the muscular efforts of the uterus to expel the 
polypus, which sometimes takes place. 

Diagnosis. — The diagnosis is easy when the polypus pro- 
trudes through the external os, but if it lies in the body of the 
uterus it may be necessary to dilate with tents and explore by both 
the sound and touch. In the former case vaginal examination 
will reveal a small, soft, pulpy mass lying in the os, which through 
the speculum will present a bright cherry-red color, contrasting 
with the darker reel of the cervical mucous membrane which sur- 
rounds it. Mucous polypi may be readily differentiated from 
fibrous polypi by their soft consistence, and the fact that fibrous 
polypi seldom present at the external os. 

Prognosis. — As a rule the prognosis is favorable. Mucous 
polypi are usually readily removed, and at all events seldom prove 
dangerous, though they may give rise, through the occurrence of 
hemorrhage, to serious anaemia, and even fatal cases of hemor- 
rhage have been known. They are not infrequently expelled 
spontaneously, but usually surgical procedures are necessary. 

Treatment. — This consists in their removal, which can be 
accomplished in different ways. 

If the polypus is small, the best plan is to seize it with a pair 
of forceps close to its insertion, and twist it off. The forceps 




Fig. 178.— Uterine Polypus Forceps, with Catch. 

should be supplied with a catch (Fig. 178), so that, while the tumor 
is steadily grasped by them, the operator's fingers are free to man- 
ipulate as may be necessary. 



276 A TEXT-BOOK OF GYNECOLOGY. 

If the tumor is large, it is better usually to cut the pedicle 
with a pair of scissors, the tumor having been grasped and pulled 
down as far as possible with the volsellum. Should polypi exist 
in the body of the uterus, the treatment is the same, except that it 
becomes necessary to dilate the cervix before they can be reached. 
This should never be done so long as the symptoms are not suffi- 
ciently grave to make it really necessary. If a number of small 
polypi are present in the body of the uterus, they -may be removed 
with the curette, Thomas' dull wire curette being the best instru- 
ment for this purpose. After the removal of polypi no form of 
local treatment is required, the application of carbolic acid, iodine, 
etc. , being entirely unnecessary ; neither is an anaesthetic required 
for the operation. 



CHAPTER XXXII. 



SARCOMA OF THE UTERUS. 



Definition. — A malignant growth, distinct from carcinoma, 
originating in the connective tissue of the uterus, and presenting 
clinical and histological features common to both fibroma and car- 
cinoma. According to Virchow they do not represent perfect 
tissue, but display only embryonic or rudimentary development. 
As carcinoma is traced back to epithelium, and fibroma to mus- 
cular tissue, so sarcoma is traced back to connective tissue. 

Pathology. — There is much confusion among pathologists as 
to the real nature of sarcoma, and the relations which exist be- 
tween sarcoma and carcinoma on the one hand, and sarcoma and 
fibroma on the other. Sarcoma is not a result of a transition of 
fibroma into a malignant form of disease, nor is it an initial growth 
of carcinoma, though, as to malignancy, apparently holding a po- 
sition midway between the two, forming, as one writer says, u a 
connective link." 

Schrceder distinguishes two varieties of sarcoma, both patho- 
logically and clinically. 

1. Diffuse sarcoma of the mucous membrane ; and 

2. Circumscribed fibrous sarcoma. 

In the first variety the disease arises from the submucous con- 
nective tissue of the cavity of the uterus, or only from the cervi- 
cal mucous membrane. 

u Under the influence of a new growth of small, round, 
rarely spindle-shaped cells, a soft, flabby, or villous tumor devel- 
ops, which grows inward into the cavity of the uterus. Thence 
it may be expelled into the cervix or vagina by the contractions of 
the uterus. It generally ulcerates only at a late stage, and perhaps 
only in consequence of the pressure exerted by the uterine walls. 
Sarcoma of the mucous membrane may, however, destroy the wall 
of the uterus secondarily by further proliferation and by destructive 
pressure upon it, or even by direct infection." 

This form of sarcoma is more closely related to carcinoma 
for the reason that there is frequently epithelial-cell proliferation 
associated with it. Klebs proposed to call such cases carcino- 
sarcomata. 

The circumscribed fibro-sarcoma arises from the muscular 
coat of the body of the uterus, only occasionally from the cervix. 



278 A TEXT-BOOK OF GYNECOLOGY. 

According to Winckel they most commonly originate in an exist- 
ing myoma, whether the latter be interstitial or submucous, but 
Schrceder says that fibro-sarcoma form round or cylindrical tumors 
of considerable size u which are quite constantly seated in the sub- 
mucous tissue." The tumors are hard, and feel like knots in the 
muscular wall of the uterus, unless, as is sometimes the case, they 
project as polypi into the uterine cavity. They thus have much 
the appearance of fibroids, but have no capsule. According to 
Schrceder, (1) microscopical examination reveals "the tumor either 
composed largely of the normal constituents of the fibro-myoma, 
with here and there, scattered throughout the mass, centres of cell- 
growth (round, or, in this form, very frequently spindle-shaped 
cells) ; or these centres of cell-growth constitute the entire mass of 
the tumor, being separated from each other by only scanty tra- 
becular of connective tissue. 

"The tumors have no tendency to break down, although, like 
the fibrous polypi, they may be spontaneously expelled. Conse- 
quently they sometimes attain a very considerable size. In a case 
which is still under my observation, where the diagnosis is scarcely 
open to question, although not yet confirmed by microscopic exami- 
nation, the tumor reaches from the entrance of the vagina to 
above the navel. These tumors may extend by continuity to the 
surrounding tissues, and also, by metastasis, involve the lymphatic 
glands or other organs." 

Etiology. — The causes of sarcoma are entirely unknown. 
The disease occurs at all periods in life after puberty, and under 
all circumstances and conditions, and is as frequent in nulliparae 
as in multiparas 

Symptoms. — The symptoms of sarcoma are hemorrhage ; 
watery, non-offensive discharge, becoming more or less offensive 
as the disease progresses ; absence of pain in the early stages, but 
labor-like pains later when the uterus endeavors to expel the new 
growth ; pressure on the rectum and bladder ; cachexia. 

Physical examination reveals practically the same signs as are 
found with fibroids. In the diffuse variety, if the tumor can be 
touched, it will be found soft, spongy and friable. In fibro- 
sarcoma it is more dense and hard, like fibroma. The uterus is large 
and irregular in shape, even more so than in the case of fibroids, 
and the sound shows increased depth. 

Diagnosis. — If the above signs are present in a tumor of 
slow growth, it may be safely presumed that it is sarcomatous, but 
the microscope is necessary to fully differentiate from either fibroma 
or carcinoma. Hart and Barbour say that this is not always decis- 



1) Ziemssen, Vol. X, p. 30. 






SARCOMA OF THE UTERUS. 279 

ive, ' ' as the cells found in sarcoma sometimes closely resemble 
epithelial cells." 

Prognosis. — The prognosis is unfavorable. While the devel- 
opment is much slower than in carcinoma, and there is less pain, 
and the offensive discharges are less than in carcinoma, yet sooner 
or later the patient will succumb in spite of operative interference. 
After removal the tumor returns, usually within a few months, 
and develops much more rapidly than did the first growth. The 
patient generally dies from spread of the disease to neighboring 
viscera, with consequent disturbances of nutrition, or from septi- 
caemia. To what extent the disease may be held in check or 
ameliorated by the use of homeopathic remedies has not been de- 
termined. It is claimed that under homeopathic treatment sarcoma 
is at least less rapidly fatal, but this may arise from the fact that 
under such circumstances the tumor is less often interfered with 
by operative measures. 

Thomas says, (1) "The microscope, to a certain extent, aids 
us in predicting the probable rapidity of the affection. The more 
nearly it approaches a hard growth, the preponderating element 
of which is fibrous tissue, the slower will be its course ; the more 
it partakes of a soft character and shows itself rich in cellular ele- 
ments, the more rapid will be its progress in molecular death. 
Again, the small-celled varieties show a more marked tendency to 
rapidity of production than those which are characterized by large 
cells." 

Treatment. — The rule is to remove such growths as soon as 
their malignancy is suspected, but when we consider what has 
already been said concerning the prognosis of sarcoma I think 
such a rule is too sweeping. The question of operative interfer- 
ence must depend upon many circumstances which cannot be here 
enumerated. The patient should be plainly informed as to the 
probable amount of benefit she will derive from surgical inter- 
ference, and her wishes should decide the question. Removal can 
be secured by the galvano-cautery, ecrasement, excision, or the 
curette, as has already been detailed under the head of fibroid 
tumors, and will be further considered under carcinoma. 

1) Op. Cit., p. 543. 



CHAPTER XXXIII. 



CARCINOMA OF THE UTERUS. 



Definition. — Cancer of the uterus does not differ essentially 
from the same disease when located elsewhere, and does not admit 
of a separate or distinct definition. According to Waldeyer, (1) 
cancer is "an atypical epithelial neoplasm. 1 ' 

Ziegler (2) defines carcinoma as " a growth characterized by 
epithelial multiplication, and not agreeing with any normal glan- 
dular type.'" 

Varieties. — There are three forms of carcinoma affecting the 
uterus: (1) Fibrous or scirrhous, hard cancer; „ (2) medullary or 
encephaloid, or soft cancer; (3) epithelioma, or cancroid. 

Scirrhous of the uterus is of extremely rare occurrence, so 
rare, indeed, that it is not described by some authorities. The 
medullary is the most common form, epithelioma occurring next 
in frequency. Either one of these forms may affect either the 
cervix or the body of the uterus, though cancer of the body of 
the uterus is of rare occurrence; Schrceder claims that less than 
two per cent, of cases aTe situated in the body. For this reason, 
and because the disease when located in the body of the uterus 
differs only in a few comparatively unessential points from cancer 
of the cervix, I shall not follow the customary plan of describing 
these as two general varieties, but will notice the differences men- 
tioned in their proper place. 

Pathology. — There is much less difference in the morbid 
anatomy and the pathology of the different varieties of carcinoma 
than is usually supposed. Ziegler (3) describes them as follows, 
though not in the order here given: 

(1) Scirrhous, or hard cancer. In this form the cell groups 
are small and scanty, and the stroma coarse and dense. The 
tumor feels firm or even hard, and looks very much like a dense 
fibroma. 

The characteristic hardness of scirrhous is found in spots, 
where the fibrous stroma is not so much alveolated as interspersed 
with small fusi-form cell-nests. 

The cancer-cells often perish by fatty degeneration, and are 



1) Billroth's Surgical Pathology, American edition. 

2) Text-Book of Pathological Anatomy, etc., W. Wood & Co., 1887, p. 23? 

3) Op. Cit. 

280 



CARCINOMA OF THE UTERUS. 281 

then absorbed. The coarse fibrous stroma is left, looking like a 
deposit of firm scar-tissue. 

(2) Medullary or Encephaloid. — When the cells are very 
abundant and the stroma delicate and scanty, the consistence of 
the tumor may become remarkably soft and semi-fluid. They 
resemble very much the softer adenomata and sarcomata. An 
abundant milky cancer-juice may be expressed from the cut sur- 
face; it contains numerous cells and free nuclei, with fatty detritus 
and free oil-globules. 

(3) Epithelioma. — Ziegler distinguishes the squamous and 
cylindrical varieties of epithelial cancer. Of the squamous variety 
he says, "the chief representative of this class is epithelioma or 
cutaneous cancroid. This gives rise to watery and nodular tumors, 
or to diffuse thickenings of the skin. It is characterized by the 
occurrence of its large epithelial nests, made up of large multiform 
squamous cells. Ulcers are very often formed by the breaking 
down of the new tissue. 

4 'If the section of an epithelioma be scraped, a gritty mass is 
obtained consisting mainly of nests and single cells. The nests 
often take the form of globes in which the cells are arranged con- 
centrically like the coats of an onion. These at times become 
horny, forming what are called epithelial pearls. Epitheliomata 
in which these pearls are a distinct feature have been called horny 
or corneous cancroids. The tumor-cells of epithelioma are descen- 
dants of the superficial epidermis, and also of the epithelia of the 
hair-follicles and sebaceous glands." 

The cylindrical variety has its seat in the mucous membrane. 
It forms soft, nodulated tumors which start in the columnar 
epithelium of the glands. 

In consequence of active multiplication among the epithelial 
ceils the glands become distended into more or less globular nests. 
By mutual compression the cells assume various forms, retaining 
their columnar character only at the periphery. Sometimes an un- 
occupied space or lumen remains at the centre. The cell-nests 
having thus the appearance of gigantic gland acini. Either of these 
varieties may include the flat conical and the papillary forms, but 
the squamous variety is that usually occurring. 

Hart and Barbour claim that ' ' we have not at present a truly 
pathological classification of the different forms of carcinoma." 
Accordingly, as a matter of clinical convenience, they use the terms 
true Carcinoma and Epithelioma. This is precisely what others 
do practically, even if, in theory, they adopt a pathological classi- 
fication. By these terms nothing is implied regarding the nature 
or origin of the disease. The term epithelioma, as used, includes 
* i those forms which begin more superficially, spread more slowly 



282 



A TEXT-BOOK OF GYNECOLOGY. 



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CARCINOMA OF THE UTERUS. 283 

and do not tend to involve the connective tissue." The origin of 
all the forms of cancer is a matter that is not yet settled, there 
being two distinct views. These are briefly shown in the accom- 
panying table taken from Hart and Barbour. Schroeder accepts 
the views of Waldeyer, as do most other authorities; yet the most 
recent investigations are those of Kuge and Veit, who claim that 
carcinoma is not epithelial, but that it arises, at least in the majority 
of cases, from the connective-tissue cells ; even the papillary form, 
which develops the so-called cauliflower excrescence, and apparently 
arises from the epithelium, really springs from the connective- 
tissue cells. The table also gives very concisely the chief clinical, 
as well as the pathological features, so that further remarks on 
the position and progress of the various forms of carcinoma are 
not necessary. 

As Schroeder says, ' ' the disease remains confined to the par- 
enchyma of the cervix for but a short time," the tendency being 
to spread and invade the adjacent tissues and organs. First, it 
may encroach upon the neighboring connective tissue of the pelvis, 
even, at times, involving the lymphatics ; second, it may advance 
upward, involving the body of the uterus, the process sometimes 
including the Fallopian tubes ; third, downward, involving the 
vagina, though generally only its upper third. From the vagina 
and connective tissue the disease may spread to the bladder and 
rectum respectively, the former being much more common, giving 
rise to vesico- and recto- vaginal fistula. Sometimes the disease 
breaks through into both the bladder and rectum, thus forming a 
vast cloaca into which all three organs open. 

Thus, in a great many advanced cases there may come to be 
one great ichorous cavity, into which the bladder and rectum open, 
and in which every trace of the uterus has disappeared. Those 
parts of the walls of this cavity which do not show evidences of 
carcinomatous infiltration are frequently covered with diphtheritic 
deposits. 

Schroeder (1) describes carcinoma of the body of the uterus 
as occurring under two different forms, either in circumscribed, 
roundish foci in the parenchyma of the uterus, or as a diffuse car- 
cinomatous infiltration, which gradually involves the whole body 
and fundus. The round nodules of the first form are of the size 
of a hazelnut, a walnut, or larger ; they very readily become 
softened, and, when broken down from necrosis, sometimes perfo- 
rate into the cavity of the uterus, where they can be felt as friable 
masses, and are gradually cast off. Sometimes they make their 
way outward, instead of inward, and then the perforation is very 
commonly preceded by adhesions to adjacent organs, or may be 

1) Op. Cit., p. 298. 



284 A TEXT-BOOK OF GYNECOLOGY. 

shut in by pseudo-membranes. On the other hand, acute periton- 
itis, from perforation, often occurs with a fatal result. There 
may, however, be adhesions to and perforation into various parts 
of the intestines or into the bladder ; in fact, by these excluding 
pseudo-membranes a completely new, sac-like space may form 
between the posterior wall of the pelvis and the symphysis, in 
which lie the broken-down masses shut out from the abdominal 
cavity, so that gradually almost the whole body of the uterus may 
be destroyed, and in its stead may be found a newly-formed cavity, 
with gangrenous contents. 

Etiology. — While there are undoubtedly certain conditions 
which predispose to the development of cancer, yet the real fons 
et origo of the disease is entirely unknown. 

Women are more subject to cancer than men, and in the 
former the uterus is the most frequent seat of the disease, cancer 
of the mammae coming next in order of frequency. The disease 
is rare in young women, being most frequent in middle and 
advanced life. Probably the majority of cases occur at or soon 
after the menopause. The disease occurs most often in the married, 
and is much more frequent in the multipara?. Many cases of 
epithelioma may be traced to cervical laceration. Heredity has 
some influence in the production of cancer of the uterus, but not 
to the extent previously supposed. Winckel says, (1) ''English 
physicians have called attention to the frequency of tuberculosis 
in the families of women who have cancer, and my experience 
confirms the observation." 

Any causes tending to depreciate the general health may favor 
the development of the disease — grief, mental trouble, exposure, 
hard labor, insufficient food and vicious habits, may be enumerated 
in the list, and this fact is said to explain why cancer occurs more 
frequently among the poorer classes. The influence of traumatism 
in the production of cancer — when not due to parturition or abor- 
tion — is a matter of question. 

Carcinoma of the body of the uterus is said to occur still later 
in life than that of the cervix, and is more often found in women 
who have not borne children. 

Symptoms.— The characteristic symptoms of cancer of the 
uterus are the same as those of cancer in other situations, viz. : — 
Hemorrhage ; 
Offensive discharge ; 
Pain. 

Generally, also, there is a cachectic condition, and more or 
less secondary disturbance of the nervous and vegetative systems, 
showing themselves in general debility, emaciation, disturbances 
of the digestion, constipation, painful defecation, dysuria and 



CARCINOMA OF THE UTERUS. 285 

pruritus vulva, to which is sometimes added vesico- or recto- vaginal 
fistula?, with their attendant evils. The cachexia referred to is 
characteristic of all cancerous patients, and is usually a sequel of 
the other symptoms. The skin acquires a dirty straw tint, and 
the face assumes a careworn expression — -fades carcinoma. Dr. 
Byford claims that this condition is not distinguishable from the 
hemorrhagic anaemia occurring sometimes in persons of the same 
age, produced by the drain upon the blood. With this statement 
I do not concur, for to the practiced eye there is certainly a 
decided difference between the appearance of a patient suffering 
from ordinary anaemia, and one suffering from cancer. 

Of the three characteristic symptoms first mentioned, hemorr- 
hage is the most constant, and is usually the first noticed, though 
it is not present in all cases. Sometimes the hemorrhage is con- 
stant, at other times intermittent, or occurring from slight causes, 
a mere touch of the finger, coition, straining, coughing, or the use 
of the speculum exciting it. Usually the hemorrhage is greater 
near the menopause, and though the amount of blood lost is some- 
times considerably exhausting to the patient, yet death from hem- 
orrhage is rare. In the later stages of the disease the hemorrhage 
may become insignificant, or cease entirely. 

As soon as ulceration has commenced we begin to have the 
characteristic discharge. This is thin and watery, pale, dirty 
looking, or tinged with blood, offensive, and sometimes corrosive 
in its character. As the disease advances and the deeper tissues 
become involved, breaking down rapidly, the discharge becomes 
thicker, usually more of a reddish brown or chocolate color, and 
the fcetor becomes more intense. The fcetor is very characteristic 
and is due to the ulceration or to the gangrenous shreds which are 
cast off from the papillomata. Sometimes a diagnosis can be made 
merely from the peculiarity of this odor. 

Pain, although characteristic, is not always of the same char- 
acter. In most cases no pain is experienced in the first stages, 
and for this reason the patient, and possibly the physician, is 
deceived as to the real character of the disease. But as the connective 
tissue becomes involved, or the organ becomes so enlarged as to 
cause pressure on the pelvic nerves, intolerable pain is experienced, 
of a lancinating, burning or dull gnawing character, which extends 
to the loins, thighs or abdomen, and is usually worse at night. In 
exceptional cases pain is not present through the whole course of 
the disease, or at least only to a limited extent. 

Carcinoma of the uterine body gives like characteristic 
symptoms. The pain comes on earlier in the disease, and is more 
variable in its character, sometimes appearing as a uterine colic, 
and occurring in paroxysms. Hemorrhage is also present early, 



286 A TEXT-BOOK OF GYNECOLOGY. 

but partakes more of menorrhagia, on account of the involvement 
of the endometrium, and is more apt to occur with alarming 
violence. The discharge is usually profuse, watery and offensive, 
and sometimes entirely absent. It does not differ essentially from 
the discharge already described. 

Diagnosis. — The diagnosis of cervical carcinoma in the later 
stages is a comparatively easy matter, but, unfortunately, this is 
not the case in the first stage. Here the diagnosis is attended with 
difficulty, which is to be deplored, for it is only at this time that 
we can have much hope of effecting a permanent cure. Spiegel- 
berg (1) calls attention to the use of sponge tents for diagnostic 
purposes in this stage. If the induration of the tissue be benign, 
the dilating influence of the tent will produce a degree of softening, 
while, if it be due to malignant disease, the tissue will remain 
unyielding and hard. Winckel opposes this conclusion. He says (2) 
that "In doubtful cases the results of dilatation cannot be relied 
upon as establishing the diagnosis, for a cancroid of the cervix 
may be rapidly and easily dilated either by tents or labor pains, 
while the converse is often true of simple indurations of the con- 
nective tissue." 

We should remember, also, that chronic induration may have 
been present for years, while the mean duration of carcinoma is 
only about eighteen months. The hardness of induration is uniform 
while that of carcinoma is nodular, the mucous membrane being 
firmly adherent, as Waldeyer says, ' ; as if fastened by the epithelial 
plugs to the subjacent tissue with little nails." Early in carcinoma 
the upper part of the cervix becomes obliterated, owing to the 
spread of the disease to neighboring tissues, while in simple hyper- 
trophy the cervix, though enlarged, is clearly defined. 

In the most of cases, however, no opportunity for diagnosis 
is given until pain or hemorrhage has called the patient's attention 
to her condition, ulceration being frequently well advanced before 
a physician is consulted. At this time a vaginal examination, 
which must be carefully conducted on account of the danger of 
exciting hemorrhage, will reveal either an irregular ulcerated sur- 
face, crumbling and brittle in character, with hard edges ; or, in 
case of papillary epithelioma, the everted lips of the cervix will 
spread out like a mushroom, and if the cauliflower excrescence 
projects from the external os it may be distinctly felt [Fig. 179]. 
On withdrawing the finger it is found stained with blood and 
retains the characteristic odor of the cancerous discharge. In the 
early stages of the disease, rectal examination affords the best 
method for ascertaining the condition of the connective tissue. 



1) Arch. f. Gyn., Bd. Ill, p. 233. 

2) Op. Cit., p. 371. 



CARCINOMA OF THE UTERUS. 



28' 



This is true, also, in the later stages if a vaginal examination 
causes much pain and hemorrhage, or is difficult on account of 
deposits within the vagina. In this way not only may the condition 
of the rectal mucous membrane be ascertained, but we can also 
establish the extent of the cancerous deposit, and the size and 
mobility of the uterus. Hypertrophy of the cervix leaves the 
uterus mobile, whereas in carcinoma it becomes fixed at an early 
stage of the disease. If the diagnosis is still in doubt, a small 
portion of the cancerous material should be removed and examined 




Fig. 179. — Cauliflower excrescence growing from the cervix uteri (Sir J. 
Y. Simpson). 

under the microscope. In this connection Thomas (1) lays down 
a series of propositions which are in accordance with the existing 
views of pathologists : — 

1. There is no typical cancer cell, which, separated from 
its surroundings and viewed as an entity, enables a microscopist 
to pronounce upon a growth. 

2. There are certain combinations of cells, alveoli, and 
stroma, which do enable a microscopist to pronounce an opinion 
as to the benignity or malignancy of a growth. 

3. This combination consists, in general terms, in the exist- 
ence of a fibrous stroma, containing ovoid alveolar spaces, filled 
with masses of cells with large single or multiple nuclei, and all 
bearing more or less closely a resemblance to epithelium." 

It may be necessary to differentiate carcinoma of the cervix 
from some one of the following lesions : — 

1) Op. Cit., p. 561. 



288 A TEXT-BOOK OF GYNECOLOGY. 

Hypertrophy and induration of the cervix, with occluded 
follicles ; 

Eversion and erosions of the cervix from laceration ; 

Syphilitic ulceration ; 

Sloughing fibrous polypus ; 

Diphtheritic inflammation of the mucous membrane (Schrceder) ; 

Sarcoma of the uterus. 

A careful examination and study of the case ought to be suf- 
ficient for differential purposes. The history of carcinoma and the 
physical signs already mentioned are found in no other character 
of lesion. Possibly the greatest danger of mistake lies in those 
rare cases of syphilitic ulceration where deep excavation takes, 
place, even to the formation of a vaginal fistula, but here the history 
of the case should certainly remove all doubt. 

The diagnosis of carcinoma of the uterine body is often very 
difficult, and sometimes it is made possible only by removing a 
portion of the diseased tissue and subjecting it to a microscopical 
examination. The cervix is usually normal, the uterus enlarged, 
usually acquiring a nodular feel, and becoming firmly fixed by 
adhesions to neighboring organs. The sound shows an increased 
depth, and its use is followed by hemorrhage. 

Carcinoma of the body of the uterus may require differentia- 
tion from — 

Retained products of conception ; 
Sloughing submucous fibroids ; 
Non-malignant fungosities in the uterus ; 
Chronic corporeal endometritis. 

The diagnosis of these conditions has already been considered. 
The presence of pain, hemorrhage and fcetor, together with an 
enlarged, fixed and nodular uterus, are never met with except in 
carcinoma. I agree with the opinion expressed by modern path- 
ologists that the continual recurrence of hemorrhage in women 
who have entirely passed the menopause may be considered an 
almost certain evidence of the presence of uterine cancer. 

Prognosis. — While homeopathic remedies undoubtedly do 
much to palliate the disease and check its progress, yet no well 
authenticated cures are reported as resulting either from constitu- 
tional or surgical treatment. In the few cures that have been 
reported there is doubt as to the correctness of the diagnosis. 
Death usually takes place in about eighteen months, except where 
life is prolonged by treatment. The disease may run a very acute 
course and terminate fatally within six months, whereas, on the 
other hand, it has, in very exceptional cases, been known to last 
ten or twelve years. 

As to the recurrence of the carcinoma after surgical treat- 



CARCINOMA OF THE UTERUS. 289 

ment, there is no doubt that the earlier the treatment is adopted, 
the longer will be the succeeding immunity from the disease, but 
in a majority of cases it will recur sooner or later and terminate 
fatally. 

Death may finally result from exhaustion, from an irritative 
fever which assumes a typhoid form, from hemorrhage, or perhaps 
more often from septicaemia. Seyf ort (1) has recently claimed that 
in the majority of cases death results from uraemia, due to com- 
pression of the ureters. 

Peritonitis, cellulitis, phebitis, or embolism are sometimes 
the immediate cause of death. 

Treatment. — In the treatment of uterine carcinoma the fol- 
lowing methods are to be adopted, according to the indications in 
each case : — (1) Hygienic ; (2) Constitutional ; (3) Palliative ; 
(4) Surgical. 

1. Hygienic. — In those cases coming under treatment in 
the earlier stages of the disease, much can be done toward main- 
taining the general health and holding the disease in check by an 
observance of proper Irygienic rules. Nutritious food, plenty of 
fresh air and sunshine, agreeable society and cheerful surroundings 
are as important as in the treatment of any other constitutional 
disease. 

2. Constitutional. — Whatever other methods of treatment 
may be adopted, the constitutional treatment must not be neglected. 
While surgical measures should not be delayed under a vain hope 
that internal remedies may eradicate the disease, yet there is 
probably no case of carcinoma, of whatever nature, but that may 
be aided by the persistent use of the indicated remedy. I have 
seen cases in which I am certain that the patient's sufferings have 
been greatly mitigated and life prolonged for years, simply by the 
use of internal remedies. After surgical treatment, also, the 
administration of proper remedies will, I think, postpone, or, per- 
haps, entirely prevent recurrence. The following remedies are 
those most often required, but their indications in this disease may 
cover so much ground, and require such careful study, that I will 
content myself with referring the reader to his materia medica, 
simply cautioning him that the remedy should be selected entirely 
upon the symptoms of the individual case, regardless of other 
considerations. A remedy that covers the case from a pathological 
standpoint will certainly possess the symptoms of the case, and 
not otherwise. 

Arsenicum, Arsenic, iod., Aurum met., Calcarea carb., Carbo 
an., Conium, Graphites, Hydrastis, Iodium, Kreasotum, Lachesis, 



1) Saxinger. Prager med. Vierteljahrsschrift. Bd. I, S. 103. 



290 A TEXT-BOOK OF GYNECOLOGY. 

Mercurius, Nitric ac, Phosphorus, Phytolacca, Sulphur, Silicea, 
Sepia, Thuja. 

3. Palliative. — In a disease like carcinoma the adoption of 
palliative treatment is often a matter for grave consideration, and 
certainly should never be resorted to so long as there is any hope 
of saving or prolonging life. At least this is the rule so far as 
concerns the internal administration of opium, morphine, chloral, 
and other anodynes. Doubtless either morphine or chloral hydrate 
may be applied locally, either in solution or in the form of vaginal 
suppositories, for the purpose of allaying pain, without obtaining 
the injurious effects that would certainly arise from the use of 
these remedies internally. Ludlam recommends the local applica- 
tion of a mixture of chloroform, glycerine and sweet oil. He also 
says that "in some cases both the pain and the hemorrhage may 
be controlled by the local employment of Hamamelis." 

Palliative treatment also includes all necessary efforts to 
control hemorrhage, secure perfect cleanliness and neutralize the 
offensive odor. 

Hot water injections are not only valuable as affording more 
or less relief to the pain, but they also fulfill a triple purpose by 
controlling hemorrhage and cleansing the parts. Hemorrhage 
may be checked by the application of Churchill's tincture of Iodine, 
or by applying pledgets of cotton soaked in a strong solution of alum, 
or a solution of persulphate-of-iron in glycerine. Some physicians 
have their patients keep ready a solution of alum to use as an injec- 
tion in case hemorrhage occurs. In case of profuse hemorrhage the 
vagina may be carefully packed with pledgets of carbolized cotton, 
each pledget having a string attached to facilitate its removal. 

For the purpose of disinfecting the discharges and neutralizing 
the offensive odor various astringents and antiseptic injections are 
recommended. If the discharge be profuse but not very offensive, 
as is the case frequently in papillary epithelioma, such astringents 
as sulphate of alumina or sulphate of zinc or tannin are usually 
employed. If the discharge is offensive, a two per cent, solution 
of carbolic acid is the best agent that can be used. Permanganate 
of potash, Chlorate of potash, Bromine, Kreasote, Iodoform, Thy- 
mol, Acetate of lead, and other agents of a similar nature are 
sometimes employed. Thomas fulfills all the indications for pal- 
liative treatment, relief of pain, control of hemorrhage and preven- 
tion of fcetor by the use of the following prescription : — 

3. — Acid carbolic (sol. sat.), 1 ijss. 
Glycerinse, Oj. 
Aluminis sulphatis, ^ xiv. 
Morphae sulphatis, gr. xvj. — M. 
S. — Add one tablespoonful to two quarts of tepid water, and use as a 
vaginal injection morning and evening by Davidson's or the fountain 
syringe. 



CARCINOMA OF THE UTERUS. 291 

The external parts should be protected from the acrid dis- 
charges by introducing carbolized absorbent cotton just within the 
vulva to cause their absorption. The parts may also be anointed 
with vaseline, or with a lotion of equal parts of olive oil and lime 
water, applied after each vaginal injection. 

4. Surgical. The surgical treatment of carcinoma of the 
uterus includes : — 

1. Application of caustics ; 

2. Scraping out diseased tissue, followed by cautery ; 

3. Amputation of the cervix ; 

4. Extirpation of the uterus. 

1. Application, of caustics. — This method of treatment is 
ideally palliative, as the effects are only temporary, there being only 
a superficial destruction of the diseased tissues, which, however, 
sometimes affords the patient great relief and prolongs life. 
Strong nitric acid or the pernitrate of mercury are the agents 
usually employed. The parts should be first thoroughly cleansed 
and dried, and the sound tissues protected from the caustic by 
packing the healthy parts of the vagina with cotton saturated 
with bi-carbonate of soda. The caustic is then applied directly to 
the diseased tissue on pellets of absorbent cotton. Thomas uses 
for this purpose the chemically pure nitric acid, which he applies 
in the following manner (1): — 

"The cervix should be exposed by a large glass speculum, 
which should be pushed with some force against the vaginal junc- 
tion, to prevent escape of acid into the vagina. The cervix should 
then be cleansed by a stream of cold water from a syringe, and 
thoroughly dried by dossils of lint, or bits of sponge. Then the 
acid should, by means of a glass pipette or rod, be thoroughly 
applied to the whole diseased surface. After this a stream of 
water should be again projected upon the cervix, and a pad of 
cotton saturated with glycerine made to envelop it. " Thomas says 
he u regards this as the best method for accomplishing partial de- 
struction of a cervix affected by a cancer, and now resorts to it 
frequently in practice with excellent results." 

He endorses the statement of Dr. Churchill, who thus speaks 
of the use of strong nitric acid as a caustic : "I have found it to 
relieve pain, arrest hemorrhage, and restrain the discharges. In 
one case, hopeless when I first saw her, life was prolonged for 
three years under this treatment." 

2. Scraping out diseased tissue, folloived by cautery. — 
In those cases where the disease is too far advanced for am- 
putation of the cervix, and in carcinoma of the body of the uterus, 
this constitutes the most important as well as the most effective 
method of treatment. The operation consists in thoroughly 

1) Op. Cit., p. 568. 



292 A TEXT BOOK OF GYNECOLOGY. 

scraping away the necrosed tissue with a curette or Simon's spoon, 
and the subsequent application to the entire raw surface of the 
actual cautery, or, as Dr. Emmett prefers, of the galvano-cautery. 
After the operation the whole surface is covered with a thick pad 
well saturated with glycerine, and this held in place by a tampon, 
which will also serve to control any subsequent hemorrhage that 
may occur. The tampon is removed on the second day, but the 
pad, owing to the hemorrhage which would follow its removal, is 
left until detached by suppuration. After suppuration has begun 
vaginal injections of a two per cent, solution of carbolic acid 
should be used every three or four hours, with the hope of estab- 
lishing a healthy granulating surface. 

3. Amputation of the cervix. — When the disease is limited 
to the cervix this operation is indicated, the details of which have 
been described in a previous chapter, and need not be repeated. It 
is important that the excision be made sufficiently high to cut 
through healthy tissue, and entirely remove the diseased parts. 
In amputation for carcinoma, Emmett advises the use of either the 
scissors or the knife, and says the ecraseur or galvano-cautery wire 
should not be employed. He favors making a clean amputation 
if possible, and covering " the stump by sliding the vaginal tissue 
over it, and securing the edges of the flaps with sutures.'* 

Marion Sims recommends leaving a raw surface, to which is 
subsequently applied strong caustics. Sims used the chloride of 
zinc, but others prefer the pernitrate of mercury. The application 
is made in the same way as recommended in a previous paragraph. 

4. Extirpation of the uterus. — In carcinoma involving the 
body of the uterus, whether primarily or by extension of the dis- 
ease from the cervix, the only hope of cure lies in a total extirpation 
of the uterus. How much hope this operation affords is a matter 
of considerable doubt. It is a fearful resource, and when we 
remember that, in most cases, at least, the disease has already 
invaded the lymphatic glands and connective tissue, insuring a 
more or less speedy return, it is a matter of serious consideration 
as to whether the ultimate benefit derived is in proportion to the 
gravity of the operation. Certainly the proportion of those who 
have survived the operation, and suffered no subsequent return of 
the disease, are appallingly few, and do not warrant assuming the 
terrible immediate risks which the operation involves. At the 
eighth annual meeting of the American Gynecological Society, 
held at Philadelphia, in 1883, the discussion was extremely antag- 
onistic to the operation. At this meeting Dr. Jackson, of Chicago, 
presented a paper on the subject which contained the following 
final summary, with which I fully agree (1): — 

1) American Gynecological Transactions. Vol. VIII. 



CARCINOMA OF THE UTERUS. 203 

"1. Diagnosis of uterine cancer cannot be made sufficiently 
early to insure its complete removal by extirpation of the uterus. 

"2. When the diagnosis can be established, there is no 
reasonable hope for a radical cure, and other methods of treatment, 
far less dangerous than excision of the entire organ, are equally 
effectual in ameliorating suffering, retarding the progress of the 
disease, and prolonging life. 

"3. Extirpation of the cancerous uterus is a highly danger- 
ous operation, and neither lessens suffering — except in those whom 
it kills — nor gives reasonable promise of permanent cure in those 
who recover. Hence it fails in all the essentials of a beneficial 
operative proceeding, and should not be adopted in modern 
surgery/' 

At a meeting of the British Obstetrical Society, in 1885, the 
above views were endorsed. The Lancet (1) concludes its notice 
of the latter debate in the following words : — 

"No evidence is as yet forthcoming that total extirpation of 
the uterus for cancer of the body either prolongs life or relieves 
suffering, while, on the other hand, the mortality after the opera- 
tion is known to be large, and early recurrence extremely 
frequent." 

At all events the general practitioner would not think of per- 
forming the operation himself. Instead of occupying space to 
describe its details, I will refer the reader to the works of 
Winckel, or Hart and Barbour, for further information. 



1) London Lancet, March 14, 18S5. 



CHAPTER XXXIV. 



DISEASES OF THE UTERINE LIGAMENTS. 

Hydrocele. Solid Tumors of the Round Ligaments. Cysts of the 

Broad Ligaments. 

Hydrocele. — This condition is rare. It may exist as an 
encysted fluid about the round ligament, outside of the perito- 
neum, or it may be in that process of the peritoneum extending* 
from the internal ring into the labium majus, known as the canal 
of Niick. In the former case an oval, translucent swelling exists 
in the inguinal canal, which cannot be returned into the abdom- 
inal cavity. It is not tender on pressure and gives rise to no 
symptoms, but may sometimes be mistaken for incarcerated hernia, 
or an ovary in the inguinal canal. 

If the hydrocele be intraperitoneal, a more or less firm, fluc- 
tuating, transparent tumor, which may be as large as an egg, is 
found in one of the labia. Aspiration gives a clear fluid. It is 
also sometimes mistaken for inguinal hernia. 

"Fluid may also collect in a sac not lined with serous mem- 
brane, but formed in the cellular tissue of the labium majus, 
which consists of two layers, prolongations of the superficial 
abdominal fascia. Between these two layers, the analogue of the 
dartos tunic, a tumor may form, which has the best claim to the 
name hydrocele" (1). 

The usual treatment is aspiration and drainage, or aspiration 
followed by the injection of a few drops of tincture of iodine. 
Sometimes the fluid can be returned into the abdominal cavity, 
and a truss worn to prevent its recurrence. 

Solid Tumors of the Round Ligaments. — These are occa- 
sionally met with, and are usually upon the right side. They 
belong to the connective tissue group, being either myoma, fibroma, 
or sarcoma. They may be intra-peritoneal, in the inguinal canal, 
or external to it in the abdominal walls, pelvic connective tissue, 
vulva, or even in "remote portions of the abdominal wall" (2). 

These tumors are of a slow growth and give rise to but few 
symptoms, these being such as are generally the result of pressure, 
and of no diagnostic value. It is sometimes quite difficult to dif- 

1) Winckel, Diseases of Women, p. 55. 

2) Winckel, Op. Cit., p. 594. 

294 



PAROVARIAN CYSTS. 295 

ferentiate these tumors from hernia, and from fibrous and sarco- 
matous growths in neighboring parts. They are said to be 
especially liable to cancerous degeneration, which is manifest by 
rapid growth, the usual cachexia, emaciation and weakness. 

The only treatment for these tumors is their early removal. 
Dr. Goodell says they are not to be touched unless the symptoms 
are exacting. According to Winckel, resection of the abdominal 
muscles and peritoneum, with ligation of the epigastric artery, 
may eventually be necessary. He says that large tumors of this 
kind projecting into the true pelvis are not suitable for operation. 

Cysts of the Broad Ligament. Parovarian Cysts. — 
These cysts are found between the folds of the broad ligament, 
and may attain considerable size, so that they have frequently been 
mistaken for ovarian cysts. They have their origin in the tubules 
of the parovarium or organ of Kosenmtiller, hence the term paro- 
varian cysts. The latter term is practically synonymous with that 
of cyst of the broad ligament, though it is claimed by some authors 
that the more simple or benign cysts spring from the broad liga- 
ment itself, while those which have a tendency to degenerate have 
their origin more frequently in the parovarian tubules. There are, 
however, no practical means of differentiation. 

Parovarian cysts are mostly found in young women, and are 
sometimes congenital. When small, they may cause no symp- 
toms, but when they have increased in size the menses become 
irregular both as to time of appearance and quantity, as a conse- 
quence of the distortion and vascular disturbances produced in the 
ovary. Striae appear when the abdomen is much distended, and 
dyspnoea, palpitation, cough and difficulty in walking occur. 

These cysts are usually unilocular, although they may be mul- 
tilocular, but, if so, the divisions are not readily distinguished. 
Their walls are usually very thin, and the fluid they contain is so 
limpid that "they yield very marked waves of fluctuation, which 
are equally distinct at every point. They can usually be distin- 
guished from ovarian cysts either by a lack of that tenseness so 
characteristic of the latter, or by varying conditions of tenseness 
and flacciclity, as if the fluid were sometimes absorbed more 
quickly than at other times. They also grow more slowly than the 
ovarian cyst, and do not exert the same profound constitutional 
impression. The facies ovariana is absent, and the health of the 
woman may in no wise be disturbed. They, indeed, in the major- 
ity of cases, seem to do no harm, and are merely annoying from 
their bulk. The fluid they contain is with rare exceptions as limpid 
and clear as spring water, but with refractive powers so high as to 
magnify the fibres of the wooden pail into which it has been 
drawn off. Owing to their very thin walls and delicate struc- 



296 A TEXT-BOOK OF GYNECOLOGY. 

ture these cysts on very slight provocation are liable to burst. On 
account of the blandness of the contained fluid this accident is 
rarely followed by collapse or by peritonitis. The rent heals up 
and the cyst usually refills; but in a large proportion of cases it 
does not, and the woman remains permanently healed. Sometimes 
they are pedunculated, but often they lie between the two folds of 
the broad ligament, having no proper stalk " (1). 

As an additional means of diagnosis we should remember 
that these cysts are unilocular, while ovarian cysts are rarely so, 
and, in such a case, if aspiration yields the clear, limpid fluid, 
without albumin, and we have associated the characteristics above 
mentioned, and, especially, if the sac does not refill after tapping, 
we may be reasonably certain that the cyst is parovarian. The 
diagnosis is, however, in many instances impossible, as in those 
cases in which the contents are similar to those of an ovarian cyst, 
and when the sac refills soon after puncture, as it sometimes does. 

Treatment. — A unilocular cyst which is presumptively paro- 
varian, though possibly ovarian, should be thoroughly aspirated, 
after which it may not refill. If, however, the fluid again accu- 
mulates, the cyst may be removed in precisely the same manner as 
an ovarian tumor. In case there is no pedicle the tumor must be 
carefully enucleated from between the folds of the broad ligament. 
If this cannot be done owing to the extension of the tumor into 
the mesocolon, a portion of the cyst may be excised, and the edge 
of the remainder stitched in the abdominal wound, and a drainage 
tube introduced. 



1) Goodell. Pepper's System of Medicine, p. 294. 



CHAPTER XXXV. 



DISEASES OF THE FALLOPIAN TUBES. 

Malformations. Stricture. Inflammation. Pyo-Salpinx. Hydro- 
salpinx. Hemato-Salpinx. Morbid Growths. 

Malformations. — Malformations of the Fallopian tubes, 
though of comparatively frequent occurrence, are of but little 
practical interest. The tubes may be congenitally occluded; be of 
unequal length; have an accessory fimbriated end; or, there may 
be varieties of what is known as Morgagni's hydatid, which is a 
cystic dilatation of the parovarian tubules. In addition to these 
anomalies, the fact that the tube originates with the uterus from 
Midler's duct, causes it to be affected by all malformations of that 
organ, and when the uterus is wanting, there is also absence of the 
Fallopian tubes. There may also occur angulations and displace- 
ments of the tubes, but these always take place as a result of other 
anomalies, such as uterine displacements, genital herniae, uterine 
and ovarian neoplasms, or on account of adhesions, the result of 
peri-uterine inflammation. They are thus associated with and 
dependent upon more important lesions, and are therefore of second- 
ary importance. 

Stricture. — I do not here refer to congenital occlusion of 
the tubes, but to acquired closure, which may result either from 
calcific deposit, senile atrophy, inflammation of the tube, pelvic 
peritonitis, tubercles, or fibrous tumors. The stricture may occur 
at the uterine or fimbriated end, or in the middle. It most often 
occurs at the fimbriated end, and is then due to catarrh of the 
tubes, which has spread to the peritoneum and set up adhesive 
peritonitis. 

Stricture may cause a retention of fluids, pus, serum or blood 
(which will again be referred to), but it is of chief importance as a 
cause of sterility when both tubes are involved. It cannot be 
diagnosticated during life, nor is there any remedial treatment. 

Inflammation ; Salpingitis. — Inflammation of the mucous 
membrane of the tubes may be either acute or chronic. Acute 
salpingitis is usually a rapid and dangerous disease. It generally 
results from rapidly spreading puerperal inflammation, but it may 
be due to gonorrhea extending from the uterine mucous membrane, 
or to irritating uterine injections extending into the tube, but in 

297 



298 A TEXT-BOOK OF GYNECOLOGY. 

either case extension to the peritoneum soon takes place and a 
violent peritonitis supervenes, which overshadows the tubal in- 
flammation. 

Chronic salpingitis is of more common occurrence, and usually 
affects both tubes. It occurs mostly in connection with chronic 
endometritis, metritis or ovaritis, thus rendering its diagnosis 
obscure and its history uncertain. According to Winckel, (1) " Its 
most frequent cause is gonorrheal and puerperal infection, though 
it may occur with myoma, carcinoma, displacements, ovarian 
disease and exanthematous and infectious diseases, such as cholera 
and typhoid fever. The menstrual colic of prostitutes is largely 
due to salpingitis, and the same complaint in young married women 
may be attributed to sexual excess during wedding tours and to 
imprudence during menstruation, dancing, riding, etc." 

The symptoms are menstrual colic, together with the usual 
symptoms of pelvic peritonitis. The result of chronic salpingitis 
in certain cases may be merely the prolongation of the duration of 
chronic endometritis. In others it may be the means of exciting, 
at any moment, dangerous inflammation of the peritoneum or 
ovary; in still others, by obstructing the tube, it may lay the seeds 
of future dysmenorrhea or of hematocele; or, if causing obstruc- 
tion at more than one point, may cause distension by the accumula- 
tion of pus, blood, mucus or serum, giving rise to the conditions 
known as pyo-salpinx, hemato-salpinx, or hydrosalpinx. 

The treatment of salpingitis consists primarily in the use of 
the remedy that may be indicated by the symptoms and in keeping 
the patient quiet, proscribing sexual intercourse, and adopting any 
other means that may assist in preventing an extension to the 
peritoneum. Consult Aconite, Arsenicum, Belladonna, Bryonia, 
Cantharis, Lachesis, Mercurius, Rhus tox. 

Pyo-Salpinx. — This consists of an accumulation of pus in the 
Fallopian tubes. Thorburn says, (2) ' k This affection no doubt 
exists in many instances of supposed ovaritis with suppuration, 
and, as has already been said, there is often much difficulty in 
differentiating it from that, or from abscess due to pelvic cellulitis. 
Nevertheless, the symptoms and signs are clear enough — upon 
paper. We have constant wearing pain in one or both groins, 
increased by every movement, by coitus, and during the menstrual 
period. We have various disorders of the menstrual function — 
entire suppression in some cases, irregularity, pain, or profuse 
increase in others. Coexistent with these symptoms, on one or 
both sides of the uterus, at a greater or less distance from it, a dis- 
tinct, soft, obscurely fluctuating swelling, ascertainable bi-manually. 

1) Diseases of Women, Parvin, p. 503. 

2) Thorburn, Diseases of Women. American Edition, p. 468. 



DISEASES OF THE FALLOPIAN TUBES. 299 

There is great tenderness in the same region, and the swelling may 
be fixed or somewhat movable, according to the presence or absence 
of adhesions. It seldom attains a very great size until after a 
considerable period, and has the laterally elongated direction and 
sausage-like shape above mentioned. Such signs and symptoms 
clearly made out, point to the existence of tubal distension, but 
not necessarily by pus. To complete the diagnosis of pyo-salpinx, 
we require a history of acute inflammation, although, like all 
similar histories, it is often difficult to elicit. The inflammation 
may be ascribed to a chill, or to sudden arrest of menstruation, 
but more frequently has arisen during the post-puerperal state, or 
during an attack of gonorrhea. Accompanying the affection, 
frequent rises of temperature and sudden chills confirm the diag- 
nosis of the purulent character of the swelling. Occasionally a 
sudden catastrophe arises, from bursting of the swelling into the 
peritoneal cavity, and a few hours may bring about a fatal collapse. 
Or the inner obstruction may give way, permitting the discharge 
of pus into the uterus, and this may happen once and again, and 
even result in permanent cure. The purulent character of this 
discharge and the temporary subsidence of the swelling then render 
the diagnosis almost complete. 

According to Dr. Emmett there arc no other means of relief 
than the removal of both tube and ovary, or Tait's operation. 

Therapeutics. 

How far appropriate internal remedies may go toward control- 
ling this and other tubal affections remains yet to be demonstrated. 
Dr. Gatchell reports a case of pyo-salpinx cured with Apis mel. 
The remedies most often required according to the symptoms of the 
individual case are: — Apis, Arsenicum, Conium, Graphites, Hepar 
sulph., Lachesis, Lycopodium, Mercurius, Silicea, Sulphur and 
Zinc. 

Hepar Sulph. — When suppuration is feared this remedy may 
be given in a high potency with the hope of preventing it, but 
more often Hepar is required in a low potency to promote an al- 
ready existing suppurative process and hasten its termination. 

Mercurius. — This is probably our most valuable remedy to 
cause an absorption of pus and bring about resolution. If absorp- 
tion has already occurred, and symptoms of septicaemia are develop- 
ing, Mercurius stands second only to Arsenicum. The symptoms 
most often calling for Mercurius under such circumstances, are 
creeping chills; much perspiration without relief; great weakness 
and prostration ; pale, earthy complexion; abdomen hard, dis- 
tended and painful. 

Silicea. — This remedy is of value in long standing chronic 



300 



A TEXT-BOOK OF GYNECOLOGY. 



cases, where the suppurative process has been long continued and 
is producing a great drain upon the system. 

Hydrosalpinx. — This condition, otherwise known as tubal 
dropsy, is a distension of the Fallopian tube with serum (Fig. 180). 
The distension may be quite marked, and be in size from that of 
an apple to a child's head and even larger, sometimes closely 
simulating a cyst of the ovary or broad ligament. There may be 
more than one stricture in the course of the tube, and therefore a 
corresponding number of cysts. The form of the tube is much 
changed, being often convoluted and bent, thickened in some places 
and thinned in others. The fluid may be either serous, muco- 




Fig. 180.— Tubal dropsy. (Boivin and Dug&s.) 



serous or granular, and may contain plates of cholesterin, and 
sometimes blood. 

Symptoms. — According to Winckel (1) the symptoms of tubal 
dropsy ''result from the condition to which it owes its origin 
rather than from its size and the pressure it causes. The chief 
symptoms of many of these affections are those of pelvi-peritonitis. 
In tubal dropsy each periodical evacuation is preceded by violent 
pain, which afterward subsides. As both tubes are usually affected, 
the patient is sterile; this is, as a rule, true when the affection is 
unilateral, for the other tube is either bent, fixed by adhesions, or 
is catarrhal. We know but little of the menstrual disorders 
dependent upon this condition. When there is a history of gon- 
orrheal infection, the symptoms are dependent quite as much 
upon the disease of the uterine mucous membrane as upon that of 
the tube." 

Diagnosis. — The diagnosis is difficult, but has often been 

1) Op. Cit., p. 496. 



DISEASES OF THE FALLOPIAN TUBES. 301 

established. Vaginal examination reveals the distended tube lying 
toward the bottom of Douglas' cul-de-sac, where it is liable to be 
mistaken for an ovarian or parovarian cyst, but rectal examination 
shows that its outline is unlike the accumulation of any other fluid 
to be found in the pelvis, for the tube as it fills twists upon itself, 
like a distended intestine. The character of the cyst contents will 
often exclude ovarian and parovarian cysts. 

Prognosis. — This is usually favorable. The accumulation 
generally takes place slowly and causes but little discomfort. The 
contents are sometimes evacuated through the uterus, giving rise 
to what is known as profluent dropsy of the uterus. Rupture of 
the tube rarely occurs, and when it does the fluid is generally so 
bland that it creates no disturbance, and the tube does not usually 
refill. This accounts for some of the reported spontaneous cures 
of supposed ovarian cysts. 

The treatment consists either in aspirating through the vagina 
or abdominal incision according to Tait's method, if the symptoms 
are sufficiently grave to render such a course justifiable. The 
remedies most often indicated are Apis and Arsenicum. 

Hemato-Salpinx. — This consists of an accumulation of blood 
within the tube. It is of rare occurrence. Dr. Emmett says he 
has never known of an instance of blood accumulating in the Fal- 
lopian tubes unless it was secondary to the retention of menstrual 
blood in the uterus, and as such it should not be recognized as a 
distinct condition. Knowing, as we now do, that the tubes may, 
and sometimes do, partake in the congestion and sanguinous dis- 
charge of menstruation, it is not surprising that a tubal dilatation 
should sometimes contain blood. The accumulation may take 
place, and, if coagulated, remain, though the tube be permeable. 
In such a case, the numerous folds in the mucous membrane cause 
the retention of the clot. But the blood does not usually coagulate, 
beins: retained bv stricture. The size of the sac is variable, some- 
times growing as large as an orange. Sometimes the walls become 
very thin, or else ulcerate, and rupture takes place, with a dis- 
charge of the contents into the peritoneal cavity, causing sudden 
death. The form and location of the tumor is similar to that of 
hydro-salpinx, and the symptoms are the same save that they are 
more uniformly aggravated at each menstrual period. 

Treatment. — Operative measures are to be avoided if possible. 
Aspiration avails but little, and either abdominal or vaginal punc- 
ture is dangerous. Tait's operation may be performed if rupture is 
imminent, and it might save life even after the perforation has 
occurred. 

Tubo-Ovarian Cysts. — This is a term applied to those cysts 
whose walls are in part formed by the Fallopian tube and in part 



302 A TEXT-BOOK OF GYNECOLOGY. 

by the ovary. They result from adhesions between the fimbriated 
end of the Fallopian tube and the ovary, with degeneration of the 
corpora lutea of the Graafian follicles thus enclosed. The greater 
part of the cyst is formed by the ovary. The contents may be 
poured into the uterus along the tube, and collapse of the sac take 
place. 

Morbid Growths. — Small connective tissue growths, such 
as cancer, sarcoma, fibroma, tubercle and lipoma, are sometimes 
discovered in the tubes at post mortem, but are never found during 
life except as associated with coexisting disease of other organs, 
and therefore are of no practical importance. 

T ait's Operation. — This consists in the removal of the uterine 
appendages. Both ovaries and tubes are usually removed, as it 
seldom happens that one tube is so diseased as to require removal 
while the other is in a healthy condition. For a description of the 
operation I am indebted to Dr. Emmett (1). 

For the operation a small opening is first made in the median 
line, about half-way between the umbilicus and the pubes. The 
abdominal parietes are usually very thick, with an inch or more of 
fat, and unyielding, so that it is difficult to accomplish the step 
properly. As a vessel is cut an assistant must seize it with a pair 
of forceps made for the purpose, and all oozing must be arrested 
before opening the peritoneal cavity. Dividing the peritoneum is 
also a step requiring some judgment; it is to be caught up with a 
fine tenaculum or forceps, and an opening made with care so as 
not to wound the intestines, which lie directly against it, or with 
only the omentum intervening. The index and middle fingers of 
the left hand are to be passed into the pelvis first in search of the 
fundus of the uterus, which is to be the guide, and from this to 
either side the finger passes along the tube to the ovary. If the 
ovary can be drawn up into the wound it is better to do so at once, 
but some judgment must be exercised as to the amount of traction 
it might be safe to exert. This is particularly the case when the 
tube is greatly distended, as rupture would readily take place and 
allow the contents to escape into the peritoneal cavity. It is better 
when this condition exists to enlarge the opening sufficiently, then 
place a sponge in position, to catch any escaping fluid, while the 
aspirator is used to draw off the contents of the tube. After this 
has been done the ligature is to be applied. The ovary can be 
drawn up into the abdominal wound, between the two fingers, so 
that it may be transfixed by a large tenaculum, or grasped by a 
strong pair of forceps, which can be clasped. As the ovary is 
drawn up with the instrument and the edges of the wound are 



1) Principles and Practice of Gynecology, p. 646. 



DISEASES OF THE FALLOPIAN TUBES. 303 

sufficiently depressed by an assistant, the tube will be brought into 
view, with a portion of the uterus. The operator must stand in a 
position facing the light, so that he can see to pass a loop, form- 
ing a double ligature, through the center of the broad ligament 
without wounding the vessels. The loop end is cut in two and one 
ligature is carried across the other to form two links when tied, or 
the tissue would split between. One ligature is then tied near the 
horn of the uterus, to include the Fallopian tube and vessels 
beneath; and the outer one is passed around the ovary and tied 
below, as this ovary is lifted up. The ovary and tube are then 
out off in one mass and as close as can be done without leaving too 
little tissue to hold the ligature. Then the appendages on the other 
side are removed in the same manner. Mr. Tait uses what he 
terms the "Staffordshire knot," which secures the parts in the 
same manner within two loops, the one being linked through the 
other. He passes a loop through the center of the broad ligament, 
then the loop is turned back toward him, so as to include the 
ovary in one part and the tube in the other. It is only necessary 
now to pass one free end of the ligature through the loop, so that 
it will lie between the two, draw both as tight as possible, tie in a 
square knot, and cut the ends off so that the stump ma)' be 
dropped back into the cavity. 

Let the reader lay a loop of cord between the index and 
adjoining finger, then turn the loop back over the top of the 
fingers, pass one of the loose ends under the loop, draw both tight, 
and tie. This will give the "Staffordshire knot." 

The ligature to be used should be silk, and properly prepared 
by being thoroughly boiled, then carbolized, kept in antiseptic 
fluid until used, and it should be handled by no one but the opera- 
tor. The peritoneal cavity must be thoroughly cleansed of any 
fluid which may have escaped from the tubes, and of all blood. 
As the fluid gravitates, it will be found chiefly in the bottom of 
Douglas' cul-de-sac. To remove this properly the left hand should 
be introduced, with the knuckles toward the intestines, and as 
they are pressed back a sponge can be passed along the palm of 
the hand to the bottom of the cavity. The abdominal incision is 
then closed in the usual manner. 



CHAPTER XXXVI. 



DISEASES OF THE OVARIES. 

Absence; Imperfect Development; Atrophy; Hemorrhage; 
Displacements; Hernia. 

Absence. — An entire absence of both ovaries is found only 
in connection with an absence of the uterus, and sometimes, also, 
of the vagina and vulva. Such cases are congenital, and are of 
very rare occurrence. Usually under such circumstances the figure 
remains undeveloped, there is no effort of nature to establish the 
menstrual functions, and the girl shows a deficient state of devel- 
opment, both mental and physical. 

Imperfect Development. — In some instances the ovaries are 
present, but fail to undergo the normal development of childhood 
and puberty, often, indeed, retaining their foetal state. If occur- 
ring in one ovary, the perfect ovary may perform its functions 
normally, but usually both ovaries are in the same condition. If 
so, the menses are entirely absent, and the girl presents none of the 
usual evidences of transition to womanhood, though the vulva, 
vagina and uterus are in a normal condition. 

Treatment. — In cases of congenital absence of the ovaries it 
is of course worse than useless to attempt any form of treatment. 
If, however, we are satisfied that the condition is only one of im- 
perfect development, and if the health is evidently being impaired, 
it is proper to attempt their stimulation and development. This 
is usually best accomplished by the use of the galvanic current. 
The positive pole should be placed over the lumbar region, and the 
ovarian region on each side treated with the negative pole. Or, 
still better, apply the positive pole to the cervix by means of an 
insulated uterine electrode. Sometimes gentle irritation of the 
uterus with the uterine sound will answer a good purpose, or the 
introduction of a slippery-elm tent. At the same time the patient 
should receive from time to time such internal remedies as her 
symptoms may indicate, and be allowed plenty of exercise in the 
open air and the benefit of such other hygienic measures as her 
condition may suggest. Often sexual intercourse will prove the 
best stimulant, marriage having in many instances brought devel- 
opment and vigor to the organs. 

Atrophy. — Normal atrophy of the ovaries takes place at 
about forty-five years of age, but may occur abnormally at a much 

:J04 






DISEASES OF THE OVARIES. 305 

earlier period, though such instances are extremely rare. If this 
condition is simply manifest by a cessation of menstruation, or 
premature menopause, and is not associated with symptoms of 
deranged health, it is not advisable to resort to treatment. If, 
however, the patient's health is suffering, she should receive about 
the same course of treatment as has already been recommended 
for an imperfect development of the ovaries. 

Hemorrhage. — At each menstrual period, when ovulation 
takes place, a normal hemorrhage, or apoplexy of the ovaries, 
takes place. This condition lasts but a short time and its effects 
readily disappear. Sometimes, however, this process becomes 
abnormal, the quantity of blood escaping being in excess of the 
peripheral follicles, leaving projecting sacs filled with slightly co- 
agulated blood, and varying in size from a pea to that of an 
orange. Should this cause a complete rupture of the tunica albu- 
ginea, the blood escapes into the pelvic cavity and constitutes pel- 
vic hematocele. Usually the apoplectic follicles shrink after the 
manner of the corpora lutea, and sometimes after the resorption 
of the extravasated blood they remain as cysts and continue to 
grow, (1) developing a cystic tumor of the ovary. There are no 
diagnostic symptoms, unless pelvic peritonitis is established or 
hematocele occurs, when we have the characteristic symptoms of 
these diseases, and should treat the case accordingly. 

Displacements. — Aside from a displacement of the ovary 
into a hernial sac, which will be hereafter considered, prolapsus of 
the ovary is the most important displacement. The ovaries, being 
extremely mobile, are quite liable to displacement, which may 
arise, according to Barnes (2) — 

1. From change in its own condition, as of bulk, the result 
of inflammation or other diseases. 

2. From pressure of other organs or structures upon it, as 
tumors. 

3. From dragging of the uterus. 

4. From inflammatory adhesions binding it down in unnatu- 
ral positions. 

5. From relaxation of the vagina and other structures, 
which support the uterus and ovaries in situ. 

According to Munde the varieties of prolapsus are — 

(1) Recto-lateral, in the lateral pouch of Douglas ; 

(2) Retro-uterine, in the true pouch of Douglas ; 

(3) Ante-uterine, in the anterior fornix, very rare ; 

(4) In the infundibulum of an inverted uterus. 

The two first named are of the most frequent occurrence. 

1) Barnes' Diseases of Women, p. 225. 

2) Op. Cit., p, 252. 



306 A TEXT-BOOK OF GYNECOLOGY. 

Symptoms. — Pain on locomotion is the most important symp- 
tom. It arises from the irritation and pressure made upon the 
prolapsed ovary while walking. The pain is referred to the inguinal 
and sacral regions, and is of a sickening and exhausting character. 
Sometimes the pain is sharp and occurs suddenly, running down 
the corresponding thigh along the track of the genito-crural nerve. 

The patient also complains of throbbing or radiating pains 
during defecation, which arises from the grating of the hardened 
feces over the tender glands. There is also pain on coition, the 
ovary lying so low down that it is bruised by the male organ. 
There is also considerable bearing down, various reflex nervous 
symptoms, and general irritability. 

Physical Examination. — Examination of this character will 
reveal in the true or lateral pouch of Douglas, one or two, as the 
case may be, very tender, almond-shaped bodies, lying distinct 
from the uterus. Pressure upon these produces a sickening pain, 
like that when the testicle is squeezed. If the pressure be increased, 
and be so made that one of these bodies slips abruptly away from 
under the finger, such a thrill of indescribable pain darts through 
the groins and down the side of the corresponding thigh that the 
woman screams out and grows pale or becomes nauseated. 

Treatment. — Remedies should be prescribed according to the 
nature of the symptoms, in order to aid in overcoming the irrita- 
tion and congestion which is almost invariably present. Hot 
water injections should be persistently used, and a glycerine tam- 
pon is often of great value. Pessaries, as a rule, do more harm 
than good. 

A very excellent way of keeping up the ovaries is the knee- 
chest posture devised by Dr. H. F. Campbell, of Georgia (1). Two 




Fig. 181. — Munde's Pessary for Prolapsed Ovary. 

or three times a day, or more frequently if needful, the woman 
unbuttons her dress, unhooks her corsets, and loosens her under- 
clothing. She then kneels on her bed with her body bent forward 
until her chest is brought down to the surface of the bed, while 

1) Pepper's System of Practical Medicine, Vol. IV, p. 288. 






DISEASES OF THE OVARIES. 307 

her head is turned to one side and the lower cheek supported in 
the palm of the corresponding hand. Her knees should be about 
ten inches apart and the thighs perpendicular to the bed. The 
trunk of the woman's body is now supported like a tripod, by her 
two knees and the upper portion of her thorax. If she now 
refrains from straining and breathes naturally, a reversal of gravity 
will be established. With the fingers of her free hand she next 
opens the vulva. Air will rush in, distending the vagina, and the 
contents of the abdomen will at once sink toward the diaphragm. 
This will, of course, draw the womb and the displaced ovaries out 
of the pelvic basin. As it is rather awkward for a woman while 
in this posture to free one hand to reach the vulva, Campbell 
advises that previously to taking this attitude she should insert 
into the vagina a small glass tube open at each end and long 
enough to project externally. This will leave an air-way and 
dispense with the use of the fingers. After staying in this posture 
for a few minutes, the woman removes the tube and slowly turns 
over on her side, where she is to lie as long as she can. Such 
constant replacements are of great service, for they lessen the 
throbbing, give the limp ligaments a chance of shrinking and of 
keeping the truant ovaries at home. 

In case the prolapsus cannot be controlled, or the ovary is 
bound down by adhesions, and the patient is suffering great in- 
convenience, the propriety of removal may be considered. 

Hernia. — The term hernia is limited to those cases where the 
ovary enters a hernial sac. The most common form is the inguinal, 
but it may occur in a crural, abdominal, vaginal, sub-pubic or 
ischiatic hernia. The difficulty is usually congenital, but may be 
acquired, and may be either single or double. 

Symptoms and Diagnosis. — There is always the peculiar ova- 
rian tenderness and nausea upon pressure, and the tumor becomes 
swollen near the time for the menstrual flow. The connection of 
the tumor with the uterus may be ascertained by drawing the 
latter down with a volsella. The diagnosis from an ordinary 
hernia is most important. 

Treatment. — Usually the ovary is fixed clown by adhesions. 
In such cases a protecting concave pad may be worn, or, if cir- 
cumstances warrant, the displaced gland may be removed. If the 
hernia is reducible, taxis should be employed, and a suitable ban- 
dage or truss should be applied. 



CHAPTER XXXVII. 



OVARIAN NEURALGIA. 



Synonyms. — Ovaralgia ; Oophoralgia; Ovarian irritation. 

Definition. — An affection of the nerves of the ovaries char- 
acterized by pain, but without inflammation or organic change in 
the organs. This disorder is extremely distressing and often lasts 
for years, making the patient's existence utterly miserable. 

Etiology. — The predisposing causes of ovarian neuralgia are, 
to a considerable extent, the same as those which predispose to 
other forms of neuralgia. An inherited nervous organization, a 
neuralgic or rheumatic diathesis, or a hysterical temperament, favor 
the development of this disease. 

The exciting causes embrace any source of nerve irritation 
liable to affect the pelvic viscera. It is, therefore, frequently 
associated with other diseases, especially those of the generative 
organs, as a purely sympathetic disorder. Marital excesses are a 
frequent cause, as is also the imperfect performance of the sexual 
act, or its entire absence, especially in widows. The normal con- 
gestion of the female organs during menstruation may excite ova- 
rian neuralgia, and it has been frequently reported as occurring 
simultaneously with the ripening and discharge of the ovum each 
month. Dr. Julia Holmes Smith very aptly says, (1) that undue 
sexual excitement, whether ligitimate or otherwise, the abnormal 
life of the society woman, with its novel-reading, theater-going, 
and social excesses, the persistent standing of young women in 
stores, wearing, as they do, too heavy skirts, high-heeled shoes, 
and corsets, all have a tendency to promote ovaralgia and other 
ultra-pelvic ailments. 

Uterine displacements and other pelvic disturbances may 
cause ovarian neuralgia, but in such instances I opine that the 
entire disorder more likely arises from a feeble nervous organiza- 
tion, and the whole may be considered as a constitutional rather 
than a local disease. 

Symptoms. — The chief symptom is a sudden and acute pain 
occurring in paroxysms, rarely affecting both ovaries at the same 
time, more often the left, but frequently alternating. The pain is 
moderated by firm pressure, which, however, at the same time 
often excites nausea and vomiting, and sometimes hysterical phe- 

1) Arndt's System of Medicine, Vol. II, p. 332. 



OVARIAN NEURALGIA. 309 

nomena. Dr. Ludlam says that, ' ' contrary to the general rule in 
neuralgia, the pain is increased by the touch and by pressure, 
whether it is slightly or more firmly applied. 1 ' But this is not 
according to the experience of other eminent observers. Dr. Lud- 
lam (1) describes the pain as being " sudden, intense, excruciating, 
stabbing, cramp-like, and is apt to be accompanied by bending of 
the body toward the affected side, by fainting, falling, vomiting, 
hysterical spasms, delirium, or diuresis. Sometimes it radiates, 
and, in chronic cases (as also those which occur in pregnancy) it 
may extend along the corresponding thigh. Usually, however, it 
is circumscribed and limited to the site of the ovaiy, which varies 
in different women and at different periods." 

TThen occurring at the period of menstruation this affection 
constitutes neuralgic dysmenorrhea, elsewhere described. 

Diagnosis. — This is usually readily established. The sudden, 
excruciating pains, relieved by pressing, and often disappearing as 
suddenly as they come, the absence of inflammatory symptoms, 
and the general history of the case, is usually all-sufficient to 
exclude ovaritis, with which it is most apt to be confounded. 

Prognosis. — Many cases are radically cured under homeo- 
pathic treatment, yet the disease is very persistent, and often gives 
rise to many sympathetic cardiac and other disturbances which 
make the patient's existence almost unendurable, though life itself 
is never directly endangered. 

Treatment. — The ordinary hygienic and dietetic rules for 
building up and strengthening the nervous system should be care- 
fully observed. Plenty of fresh air and sunlight; systematic 
moderate exercise ; regularity of habits ; nourishing food, such as 
meat, eggs, milk and oysters ; proper clothing, especially flannel 
over the hypogastric region, and pleasant surroundings are of the 
utmost importance. Abstinence from sexual excitement or indul- 
gence must be observed. Often the most radical change of habits 
are necessary, and can only be accomplished by means of great 
tact and persistence. 

During the attacks hot applications afford the most immedi- 
ate relief. Hot fomentations, hot salt bags, or, still better, a rub- 
ber bag filled with hot water. Chloroform liniment often gives 
relief. Sometimes hot water vaginal injections afford great relief. 
A vaginal or rectal injection composed of chloroform one drachm, 
and olive oil and glycerine each one ounce, is mentioned by Dr. 
Ludlam. If the rectum is loaded with feces, relief of the pain is 
often experienced immediately after their removal by an enema. 
Under no circumstances should resort be had to the use of mor- 
phine. 

1) Lectures on the Diseases of Women, p. 759. 



310 A TEXT-BOOK OF GYNECOLOGY. 

Therapeutics. 

Cimicifuga. — A valuable remedy, especially when the left 
ovary is involved, and in patients of rheumatic or neuralgic diath- 
esis, who have dysmenorrhea or amenorrhea. 

Belladonna. — Enlargement of the right ovary, with pressure 
downward, as if everything would be forced out of the vulva ; 
pains circumscribed and stabbing, or darting and lancinating ; the 
pains come and go suddenly; cerebral disturbances and spasms. 

Bromide of Ammonium. — Ovarian neuralgia; dull constant 
pain and hard swelling in left ovary ; uterine hemorrhage from 
ovarian irritation or inflammation. 

Colocynth. — I find more useful than any other remedy. 
Stitches in ovaries, diarrhea, colic, pressure in abdomen, tenes- 
mus, or intense boring tensive pain in ovary, causing her to draw 
up double, with great restlessness. 

Ignatia. — When caused by grief or sorrow ; sharp, irritating 
pain ; hysteria ; involuntary sighing ; despondency. 

Lilium Tigrinum. — The ovary feels as if squeezed in a vise, 
with stinging, darting pains ; sensation of swelling and tenderness 
to firm pressure, relieved by moderate pressure and gentle rub- 
bing ; sympathetic cardiac disturbances. 

Also consult Aconite, Chininum sulph., Zincum, Conium, 
Platinum, Ferrum, Naja, Gelsemium, Veratrum viride, Vibur- 
num op. 



CHAPTER XXXVIII. 



INFLAMMATION OF THE OVARIES. 

Synonyms. — Ovaritis; Oophoritis; Peri-oophoritis. 

Definition. — An acute or chronic inflammation of the tissue 
composing the ovaries. 

Varieties. — There are two varieties of ovaritis, the paren- 
chymatous, or follicular, in which the tissue proper of the gland 
— the Graafian follicles — is involved, and the interstitial, in which 
the connective tissue stroma is inflamed. Some authors also 
mention a simple inflammation of the investing membrane, but it 
can scarcely be shown that this form exists independent of the 
interstitial variety, which most frequently occurs as an extension 
of peritonitis. 

Follicular ovaritis is of most frequent occurrence, being often 
present in the course of acute febrile diseases. This form is of 
importance only because, when it attains a very high degree, it 
may end in destruction of all the follicles, and so result in sterility. 
Follicular ovaritis also occurs in connection with inflammation of 
the neighboring serous membrane, as in peri-metritis and peritonitis, 
but in these cases it is only of secondary importance, as the changes 
in the peritoneum are far greater and more dangerous. The inter- 
stitial variety is the form met with in connection with suppressed 
menstruation (1). 

Acute Ovaritis. — Outside of the puerperal state, which I 
shall not consider, uncomplicated acute ovaritis is a very rare 
disease, but it often occurs in connection with pelvic peritonitis or 
pelvic cellulitis. 

Dr. Matthews Duncan regards all peri-uterine inflammations 
as always symptomatic affections; as secondary to uterine, tubal 
or ovarian disease, or noxious discharges entering the peritoneal 
cavity through the tube. While probably so sweeping an assertion 
can hardly be sustained, yet it is quite certain that very intimate 
relations exist between inflammation of the ovaries and pelvic 
peritonitis and cellulitis, though it is more than likely that the 
ovaritis is sometimes, at least, the primary disease. 

Etiology. — As has already been intimated, pelvic peritonitis 
and pelvic cellulitis are the most frequent causes. Acute ovaritis 
may also be caused by taking cold during menstruation; by acute 



1) Sehroeder, Ziernssen, Vol. X, p. 351. 

311 



312 A TEXT-BOOK OF GYNECOLOGY. 

infectious and febrile diseases; by the use of instruments in explor- 
ing the uterus, and after surgical operations upon the pelvic 
viscera. So, too, may be noted any of the causes which give rise 
to peritonitis or cellulitis. 

Symptoms. — In addition to the chill, fever, excessive sensi- 
tiveness, etc., which are indicative of peritonitis, the patient com- 
plains of a deep-seated pelvic pain, pain at the side radiating to 
the back, and pain on pressure, in the iliac fossae. Bi-manual 
examination reveals the ovaries considerably enlarged, often about 
the size of a walnut, mobile, and very sensitive, pressure causing 
great pain of a sickening character. These symptoms may subside 
upon the occurrence of resolution, in four or five days; or, pus 
formed within the gland may be discharged into the peritoneum, 
the rectum, the vagina, or the bladder; or, the symptoms may 
become less intense and the inflammation assume a chronic form, 
with frequently occurring attacks of local peritonitis. If an 
abscess of the ovary occur, we have, according to Barnes (1), the 
following terminations: 

1. The ovary may burst into the peritoneum, causing abdom- 
inal shock, collapse, or peritonitis. 2. Small perforations may 
take place, exciting more circumscribed peritonitis, and leading to 
plastic effusions surrounding the diseased ovary. 3. Adhesions 
may be formed within the bladder or intestine, and a fistulous 
communication be established, by which the pus may be more or 
less completely discharged. 4. The suppurating ovary being the 
focus of a pelvic inflammation, by discharging into the rectum, 
vagina, or externally above Pourpart's ligament. 

Diagnosis. — The intimate association of acute ovaritis with 
other pelvic inflammations renders it impossible to positively 
differentiate it from these diseases. 

Prognosis. — The prognosis is usually favorable. Under 
homeopathic treatment resolution rarely fails to take place within 
a few days. 

Treatment. — The patient should be kept quiet, and either 
dry heat, hot fomentations, or the hot water bag applied to the 
surface. Hot water vaginal injections should be used, and care be 
taken that the rectum be not allowed to become loaded with feces, 
frequent enemata being usually desirable. 

The chief remedies are — 

Aconite. — In the beginning of the attack; chill; high fever; 
restlessness, and the usual symptoms of acute inflammation. 

Belladonna. — Circumscribed, darting, lancinating pains; 
intense local inflammation; flushed face, throbbing carotids and 
bounding pulse. * 

1) Diseases of Women, p. 266. 



CHRONIC OVARITIS. 313 

Bryonia. — Often follows Aconite well, or Belladonna after 
the more violent inflammatory symptoms have subsided. Sharp 
stitching pains, worse from taking a deep inspiration or from the 
least pressure or motion. 

If suppuration occurs, consult : Arsenicum, Cinchona, Hepar 
suiph., Lachesis, Mercurius, Silicea. 

Chronic Ovaritis. — The chronic form of ovaritis is not un- 
common, though of how frequent occurrence it is not possible to 
exactly estimate, owing to the probable fact that many obscure 
diseases of the Fallopian tubes, ovaries and other pelvic viscera, 
including peritonitis, are often diagnosed as ovaritis. 

Etiology. — Chronic ovaritis often succeeds the acute form 
and the causes are similar to those which induce the latter. Espe- 
cially do we find that chronic ovaritis is usually coincident with 
cellulitis and peritonitis, and probably secondary thereto. Chronic 
ovaritis may also arise from the irritation of uterine tumors or 
displacements, subinvolution, or from a lacerated cervix or peri- 
neum. Also from excessive sexual indulgence and onanism, or, 
on the other hand, from absence of sexual gratification, or an im- 
perfect performance of the sexual act. It may also arise in women 
who are sterile, the normal menstrual congestion not receiving 
the rest nature has intended during the period of pregnancy and 
lactation. 

So, too, do emotional disturbances sometimes serve as important 
etiological factors; disappointed love, unhappy marriages, corrupt 
literature, etc., are not uncommon causes. 

Symptoms. — The symptoms of chronic ovaritis are about the 
same as in the acute form, though much milder in degree, and 
presenting a chronic history. They are often numerous, and quite 
perplexing, no two cases presenting precisely the same features. 
Sometimes the symptoms are entirely physical, while at other 
times mental phenomena are prominent. In most cases there will 
be found a fixed, heavy pain or ache over one or both ovaries, 
more especially the left, increased by walking or standing and 
from pressure, better upon lying down; also pain starting usually 
from the ovary and radiating to the small of back, the rectum, or 
down the inner side of the right thigh. This may take the form 
of dysmenorrhea, the pains beginning several days before men- 
struation, increasing gradually until the flow appears and then 
gradually abating. Usually in the earlier stages the menses are 
increased in quantity and frequency, and severe hemorrhagic 
attacks may occur at irregular intervals, but later the flow becomes 
either diminished or suppressed, probably on account of the folli- 
cular structure having become impaired. Leucorrhea is usually 
present, but cannot be considered a diagnostic symptom. 



314 A TEXT-BOOK OF GYNECOLOGY. 

Sterility is a usual consequence of chronic ovaritis, and by 
some authors it is enumerated as a symptom. It may result on 
account of the pain rendering complete copulation impossible, but 
more likely from the fact that adhesions are present or that the 
follicles of the ovaries are obliterated, either from atrophy or in- 
duration. Sterility, however, is not a necessary consequence, as 
both ovaries may not be implicated, or, if they are not involved to 
an extent sufficient to cause an entire obliteration of all the fol- 
licles, those remaining in a healthy condition may produce ova. 

If the ovary be prolapsed, there is usually painful coition and 
also pain and exhaustion on defecation. 

Various reflex nervous symptoms and functional disturbances 
may arise, only less protean in their character than those of hysteria, 
which itself is often, in its various manifestations, a prominent 
feature of this disease. 

Physical examination reveals either behind or on one or both 
sides of the uterus, a round, soft, tender body, about the size of an 
almond, extremely sensitive to pressure, which usually produces 
nausea and a tendency to hysteria. 

Prognosis. — Chronic ovaritis seldom proves fatal, but it is a 
very intractible disease, and sometimes proves incurable. The 
secondary results are often more to be feared. Suppuration some- 
times results, and a destruction of the organ follows. In addition, 
the patient is subject to peritonitis, and other dangers usually 
associated with ovarian abscess. In fact, Aran holds that the 
greatest danger of chronic ovaritis is the constant liability to peri- 
tonitis, even without suppuration. Sometimes the ovaries become 
fixed by adhesive bands, with the usual results — amenorrhea, 
dysmenorrhea, and possibly sterility. Sterility may also result 
from consequent atrophy, or induration, as already mentioned. 

Sometimes cystic degeneration results, and we have an ova- 
rian tumor requiring surgical interference. 

Treatment. — The hot water douche should be employed 
daily, or, if this cannot be done, a hot sitz-bath should be used. 
The glycerine plug may be employed as often as two or three 
times a week. It is made as folloAvs : Take a square piece of 
absorbent cotton-wool about the size of the palm of the hand ; 
pour on its center about two drams of glycerine ; turn the corners 
over and squeeze the whole so as to saturate it ; lastly, tie a piece 
of thread, about eight inches long, around it. Pass Sims' or Fer- 
gusson's speculum, and place the plug in the fornix below the 
ovary. It should be left in from 18 to 24 hours, and then with- 
drawn. This plug reduces congestion, owing to the affinity of 
glycerine for water, has an antiseptic action, and, as we shall see, 
forms an admirable pessary. It sets up a watery discharge, for 
which the patient should be told to wear a diaper. 



CHRONIC OVARITIS, 315 

According to Dr. Goodell, (1) "The best of all treatments, 
and by far the best, is that devised for nerve exhaustion by S. 
Weir Mitchell, which goes by the name of the rest-cure. It con- 
sists of a prolonged rest in bed, seclusion from friends, massage, 
electricity, muscular movements, and a diet consisting largely of 
milk. By this treatment the circulation of the blood is made 
equable, and the ovaries and other pelvic organs are thus relieved 
of their turgescence. I have had wonderful cures from this treat- 
ment, and can recommend it with the utmost confidence. Bed- 
ridden patients have been restored to health, and chronic invalids 
returned to society." Sexual intercourse should be prohibited 
unless the desire is so strong that the patient is suffering from it, 
or, unless there is a hope of producing conception, thus giving the 
ovaries a prolonged rest during the period of gestation and lacta- 
tion, which is very desirable, and may in itself effect a cure. 
During the menstrual period the patient should, most of the time, 
remain in a recumbent posture, but at other times she is to be en- 
couraged to moderate and systematic exercise, though never 
carrying this to the point of over-fatigue. Dr. Ludlam recom- 
mends the external use of Hamamelis, and if the ovaries are 
prolapsed a solution of Hamamelis, with Glycerine added, as a 
vaginal injection. 

As might be expected, chronic ovaritis, with its various com- 
plications, may cause to be indicated almost any remedy in the 
Materia Medica. Those most often used are the following : 

Apis. — -Stinging, burning pains ; enlargement of right ovary, 
with pains in left pectoral region and cough from sympathy ; 
especially when right ovary is involved. 

Belladonna. — Dr. Ludlam says this remedy is especially 
useful when the attack is ushered in by marked symptoms of lo- 
cal congestion. The pains are circumscribed and stabbing in 
character, darting and lancinating; cerebral disturbances and 
spasms. 

Cimicifuga. — I consider this our most useful remedy. Ova- 
ritis with irritable uterus ; hysterical symptoms and rheumatism ; 
irregular, suppressed or painful menstruation. 

Colocynth. — Ovaritis supervening on abortion ; stitches in 
ovaries, diarrhea, colic, pressure in abdomen, tenesmus, or intense 
boring tensive pain in ovary, causing her to draw up double with 
great restlessness. 

Ignatia. — Caused by disappointed affection or trouble, invol- 
untary sighing, great despondency; weak empty feeling of stomach. 

Also consult Cantharis, Conium, Hepar sulph., Gelsemium, 
Lachesis, Mercurius vivus., Nux vom., Platinum, Staphysagia, 
Veratrum viride, Zincum. 

1) Pepper's System of Medicine, Vol. IV, p. 286. 



CHAPTER XXXIX. 



OVARIAN TUMORS. 



Varieties. — Owing to the comparatively modern history of 
ovarian pathology as relating to tumors, there are scarcely any 
two authors agreeing upon the subject, and, therefore, little uni- 
formity of opinion as regards their varieties or mode of origin. I 
shall attempt to describe only such varieties as are well established, 
and which are likely to be met with in practice. They may be 
divided in general terms into solid and cystic, either of which may 
be either benign or malignant. The following table will best 
explain their relations : 



Ovarian 
tumors: 



Solid 
tumors : 



Cystic 
tumors : 



Carcinoma; 



[ Fibroma. 



' Cysto-carcinoma; 

Cysto-fibroma, or, Sarcoma; 

Dermoid cysts; 

Follicular cysts, or hydrops folliculorum; 
^Cystoma. 



Solid tumors are very rare, of slow growth, and seldom reach 
a large size. 

Solid Carcinoma. — Cancer of the ovaries rarely occurs as 
a primary disease, but usually as secondary to cancerous disease 
in other organs. It may be in the form of a true scirrhous degen- 
eration, and present the same characteristics both in symptoms 
and physical appearance as scirrhous in other organs, and may 
vary in size from that of a walnut to a man's head. The tumor 
may present a nodular appearance, or, if the whole gland be in- 
volved, the cancerous mass may retain very nearly the form of 
the ovary. 

The ovary may also be the seat of medullary cancer deposit, 
"which may originate in the vesicles of DeGraaf; in a corpus 
luteum, as Rokitansky once saw it do; or in the stroma of the 
organ. Distension sometimes causes rupture of the tunica albuginea 
of the ovary, and then an exuberant medullary growth develops 
in contact with the peritoneum and abdominal viscera" (1). 



1) Thomas, Diseases of Women, p. 653, 



316 



OVARIAN TUMORS. 317 

Cancer of the ovary usually, but not always, forms adhesive 
connection with neighboring organs, and thus becomes fixed and 
immovable. According to Thomas, (1) "The symptoms which 
generally point to the malignant character of an ovarian tumor are 
these: 

" 1. The rapid development of a solid tumor in an ovary. 

" 2. Marked depreciation of the strength, vital forces, spirits, 
and general condition of the patient. 

" 3. The occurrence of oedema pedum and spansemia, with a 
small tumor, which are consequently dependent upon a general 
blood state, and not upon the results of pressure by the tumor. 

' ' 4. Lancinating and burning pains through the tumor. 

"5. Cachectic appearance. 

" 6. The occurrence of ascites without evidences of cirrhosis 
or other hepatic disease, organic disease of the kidneys or heart, 
or chronic peritonitis." 

In most instances the hardness of the tumor, together with 
its nodular surface, will be an important aid in diagnosis, as will 
also the fact that usually the cervix is deeply retracted into the 
vaginal vault, and that ordinarily both ovaries are involved. The 
treatment is purely palliative. Often the indicated remedy will 
relieve the patient's sufferings and prolong life, but a cure is 
impossible. For this reason surgical interference should not be 
emplo} T ed. 

Fibroma. — Fibrous tumors of the ovary are of very rare 
occurrence, and seldom attain a large size. They invoke the 
whole organ, and sometimes undergo partial degeneration into 
bony or cartilaginous structures. Their general structure re- 
sembles that of an ordinary fibroid tumor of the uterus, being 
composed of connective tissue and smooth muscular fibre, the 
result of hypertrophy of the stroma of the ovary. 

Fibrous tumors of the ovary may cause some disturbance of 
the system, but present no characteristic symptoms. 

The diagnosis from a pedunculated fibroid of the uterus is 
practically impossible. From an ovarian cyst it can be distin- 
guished by its hardness, its slight mobility, and its gradual growth ; 
and from cancer by its gradual growth and symmetrical surface, 
and by the fact that it can be isolated. The prognosis is more 
favorable than in other forms of ovarian tumors. They grow 
slowly, as a rule, and cause but little inconvenience, though some- 
times giving rise to local peritonitis and consequent ascites. Some- 
times they cease growing and remain stationary during life. 

The treatment is purely symptomatic. Only occasionally 
does their size and the disturbance they create make it necessary 
to remove them, and in such cases ovariotomy may be performed. 

1) Op. Cit., p. 654. 



CHAPTER XL. 



CYSTIC TUMORS OF THE OVARY. 

Cystic tumors of the ovary are of far more frequent occur- 
rence than the solid variety. They are divided for clinical pur- 
poses into simple unilocular cysts, or mono-cysts, and compound 
or multilocular, or poly-cysts. They may be purely cystic in their 
character, or be complicated with cancerous or sarcomatous degen- 
eration. There is also a distinct variety known as the dermoid cyst. 

Cysto-Carcinoma. — This may be the result of a cancerous 
degeneration of a benign cyst, or the cystic growth may develop 
secondarily from a previously existing cancer of the ovary, so that 
we may have cancer complicating cystic degeneration, or cystic 
degeneration complicating cancer. Sometimes the carcinomatous 
condition may be detected by the application of the rules already- 
mentioned for solid carcinoma, but it must be remembered that 
cancer may be present and none of these conditions be fulfilled, 
the naked eye not being able to discover any signs of malignancy. 
In such instances the patient may recover from an operation, but 
will die a few months later of cancer of the peritoneum or other 
organs. 

The course of development of cystic cancer is exceedingly 
rapid, and the limit of life much shorter than in any other form 
of ovarian disease. 

Treatment. — If the cancerous development is such that no 
doubt as to its presence can exist, there can be no hope from sur- 
gical interference. If, however, there is doubt upon the subject, 
the best plan is to resort to an operation at once, hoping that the 
cancerous disease may still be localized, and no adhesions formed 
with the neighboring parts. In such cases Dr. Goodell recom- 
mends that the pedicle be burned in preference to using the liga- 
ture. Where an operation is not considered justifiable the fluid 
may be drawn off by the aspirator when necessary, but this should 
be done as seldom as possible, as even aspiration may tend to 
hasten the cancerous disease. 

Cysto-Fibroma or Cysto-Sarcoma. — There is no practical 
distinction between these two varieties of ovarian disease. Some 
pathologists mention only fibroma, and do not refer to sarcoma, 
while others describe sarcoma and say nothing about fibroma. 
Scanzoni defines the fibroma to be "tumors formed by cellular 

318 



CYSTIC TUMORS OF THE OVARY. 319 

tissue,' 1 and sarcoma, "tumors composed of cellular tissue in the 
middle of which are formed more or less considerable cavities." 
Kindfleisch says, ' ' I cannot separate the fibromas from the sar- 
comas," and farther on says, "we distinguish three principal 
varieties of sarcoma, namely: round-celled sarcoma, spindled-celled 
sarcoma, and fibroma." Certain it is that there are no ex- 
ternal signs by which the two varieties may be distinguished from 
each other. 

These tumors are of slow growth, but sometimes, especially 
if sarcomatous, they attain an immense size. Their history is 
that of a cystic and fibrous growth combined, the preponderance 
of either the fluid or solid elements giving to the tumor its char- 
acteristics. In tumors in which the solid matter preponderates it 
is sometimes difficult to distinguish it from a solid tumor. So, 
also, if the fluid predominates, it is difficult to distinguish it from 
a true ovarian cyst. 

Cases where the tumor grows to a very large size are usually 
sarcoma. The more the sarcomatous condition is present, the 
nearer do the symptoms approach those of malignancy, and the 
more rapidly fatal are the results. Dr. Ludlam gives the follow- 
ing differential parallel between the more important symptoms of 
cysto-sarcoma and cysto-carcinoma (1): — 

Ovarian Cysto-Sarcoma. Ovarian Cysto-Carcinoma. 

The rounded outline of the tumor. The surface of the tumor is irregu- 

lar and nodulated. 
The tumor is not especially sensi- It is almost always tender and 

tive. sensitive. 

There is almost always a history Menorrhagia is exceptional, 

of menorrhagia. 

Almost never a pronounced asci- Ascites and anasarca are the rule, 

tes, or any dropsy of the feet. and not the exception. 

The pulse is not habitually rapid. The pulse is like that of phthisis. 

There is no peculiar cachexia. In a confirmed case the cachexia 

is always present. 
The solid portion of the tumor de- The more malignant the solid 

velops slowly. growth, the more rapid its develop- 

ment. 

The treatment consists usually in the removal of the growth. 
The operation is more dangerous than in uncomplicated ovarian 
cysts, owing to the greater danger of adhesions and the semi- 
malignancy of the tumor. Sometimes it is better to allow the 
patient to wear an abdominal bandage, and endeavor to relieve the 
symptoms by the use of the indicated remedy, than to assume 
the risks of an operation. If, however, the symptoms become 
grave, ovariotomy should be performed without delay. 

Dermoid Cysts. — This term is applied to cystic growths of 
the ovary, which contain not only a gelatinous fluid similar to that 

1) Arndt's System of Medicine, Vol. II, p. 372. 



320 



A TEXT-BOOK OF GYNECOLOGY. 



found in other forms of ovarian cyst, but which contain also the 
elements of embryonic development, such as teeth, hair, bone, 
nerve matter, muscle, cholesterine and sebaceous matter, the whole 
being enclosed in a wall composed of an outer or fibrous coat and 
an inner one composed of true skin. They are always con- 
genital, but may not noticeably develop until after puberty. 




Fig. 182. — Dermoid cyst of right ovary containing hair and sebaceous 
matter. 

They are unilocular, involve but one ovary, and may form 
on the surface, or within the substance of the ovary. They 
rarely exceed the size of an orange. They were formerly supposed 




Fig. 183. — A bone resembling the lower jaw; d, taken from a dermoid cyst 
of the left ovary. It contained an incisor (a), a cuspid (6), four molars 
in a row, and an isolated one with three roots (c). 

to be the result of an imperfect ovarian pregnancy, but as dermoid 
cysts have been found in other parts of the body, including the 
male testes, this theory has long since been exploded. The view 
of the origin of these cysts now generally received is, that they are 
congenital, and due to a displacement of the external layer of the 
blastoderm. From this layer the epidermis and other structures 



DERMOID CYSTS. 321 

are developed, and it is supposed that a portion of it becomes in- 
cluded in the part of the middle layer from which the ovary is 
formed, and forms the rudiments of cysts of a dermoid character. 

Dermoid cysts frequently remain stationary in their congeni- 
tal state, and are never discovered, or are discovered by accident. 
Sometimes they undergo rapid development, but usually their 
growth is slow. Sometimes they inflame and suppurate, forming 
an abscess which may discharge into the peritoneum with fatal 
consequences, or, more often, into the rectum or bladder, the solid 
contents being thus evacuated. Occasionally they ulcerate into 
the vagina, or through the abdominal wall. In such cases a cure 
may not result, the suppuration continuing, with hectic fever, 
exhaustion and death. 

The diagnosis from an ordinary cyst cannot be established 
until after incision, as their mode of development and their con- 
sistency may be the same. 

The treatment is removal by ovariotomy in case the disturb- 
ance created by the tumor requires it; otherwise they should not 
be interfered with. 



CHAPTER XLI. 



TRUE CYSTS OF THE OVARY. 
Varieties and Pathology. 



Having briefly disposed of the rarer forms and complications 
of cystic growths, it now remains to notice the most frequent and 
most important of all cystic developments, the uncomplicated or 
true ovarian cvst. In addition to the clinical division of ovarian 




fldcAeM 



Dutcfischnit^ 



Jlransen 



Fig. 184.— Ovary with Dropsical Follicles. (Natural size.) a, b, three large 
cysts; c, d, e, Oberflache, surface of the ovary, Durchschuitt, section; 
Fransen, fimbriae. 

cystic growths already mentioned, two varieties of true cysts may 
be clearly distinguished : (1) Dropsy of the Graafian follicles 
or hydrops follicularis, and (2) Cystoma. 



TRUE CYSTS OF THE OVARY. 323 

Hydrops Follicularis.— This is the least important form 
of cystic degeneration. (Fig. 184.) According to Schroeder, 
(1) they represent a so-called retention cyst, and are to be con- 
sidered in the same group with tubal dropsy, hematocele, etc. 
They are generally small, not larger than a cherry, and hence 
often remain undetected during life. They may occur singly, or 
exist in great numbers. In such instances a cluster of cysts, often 
forming a tumor as large as a foetal head, is found, which on sec- 
tion presents a multilocular cystic appearance. It is supposed that 
they owe their origin to an abnormal thickness of the walls of the 
follicles, or other causes which may hinder the rupture of the fol- 
licles. The presence of these cysts before puberty, and even in 
new-born children, however, demonstrates the fact that a failure on 
the part of the follicle to rupture is not the sole cause, but that 
the growth may be due in adults, as well as in children, to a hyper- 
secretion of the follicular fluid. According to Rokitansky a folli- 
cular cyst may arise from a ruptured Graafian follicle or corpus 
luteum, the kernel of the latter becoming a cyst. Follicular cysts 
have usually thick walls, of a structure similar to that of the Graafian 
follicle ;. a fibrous coat, derived from the stroma of the ovary, an 
inner coat on which thee pithelial lining is placed, corresponding to 
the tunica propria of the follicle. Their contents are a clear fluid, 
and the ovum has, in some instances, been found in such cysts. 

Cystoma. — This is the most important variety of all cystic 
growths, for the reason that it is of most frequent occurrence. 
Fortunately, too, it is most often susceptible of relief by surgical 
measures. The histogenesis of cystomata is not well understood 
even at this day, and a great variety of opinions exist among 
pathologists as to the origin of ovarian cysts. For this reason the 
literature upon the subject is exceedingly confusing, especially to 
the beginner. I shall, therefore, endeavor to give, in as concise 
a manner as possible, the generally accepted views as to the origin 
of ovarian cysts, considering, as I do, that any attempt to enumer- 
ate and discuss the various alleged sources of cystic degeneration 
would be confusing, and of no practical benefit. 

Waldeyer classifies ovarian cysts proper into two varieties, 
viz. ; Cystoma ovari proliferum glandulare, and (2) Cystoma 
ovari proliferum papillare. He considers that both of these vari- 
eties are developed from the processes of epithelium, known 
as Pflitgers ducts. They arise, therefore, from the same source as 
the Graafian follicles, the latter not normally developing, or else 
the follicle is converted into a cystoma by repeated proliferation 
of the epithelium of its inner surface. This growth by prolifera- 
tion of the interior of the cyst gives the basis for the above 
classification into the glandular and papillary varieties. 

1) Ziemssen, Vol. X, p. 362. 



324 A TEXT-BOOK OF GYNECOLOGY. 



In the glandular form, sections through the cyst- wall every- 
where exhibit small, simple, tubular "epithelial pits (almost always 
cylinder-epithelium) in the substance of the wall, which present 
the character of a glandular formation. The mouths of these tubes 
soon become stopped up by tough secretions, and then, almost 
exactly as other ' ' retention-cysts " form, they become first distended 
pouches, and then small sacs. Upon the interior of the walls of 
these sacs new depressions form, which in their turn deepen and 
form pouches and cysts, and so on. Thus a honeycomb appear- 
ance is produced. In the papillary cystoma the proliferation of 
the connective tissue of the cyst-wall is the main feature. From 
their inner surface numerous ramifying, shaggy, highly vascular 
vegetations sprout. Sometimes these are circumscribed, growing 
only within a certain limit ; sometimes they increase incredibly, 
filling the whole sac. These two varieties may combine more or 
less, and thus give rise to many diverse forms. 

Ovarian cysts are closely related to the pure adenoma, and 
many authors insist that all ovarian tumors are more or less adeno- 
matous, but according to Waldeyer the large cavities which are 
always present in ovarian cysts do not occur in adenoma, and for 
this reason he prefers to call them by the name of myxoid cystoma. 
wt When of some duration, the secondary cysts cause the wall of 
the principal cyst to be thickened and prominent on the inner sur- 
face, while deposits are formed on the outer one. Adhesions 
between the cysts and the abdominal organs are not developed for 
a long time, on account of the cylindrical epithelium covering the 
outer surface of the cyst, but they are finally produced by its 
continued growth and friction. The latter destroys the epithe- 
lium, and adhesions are formed which unite the cysts to all adja- 
cent organs" (1). 

Firm and gradually increasing peritoneal exudates are depos- 
ited between the organ and tumor near the vessels, which serve to 
connect them. 

The inner surface of a myxoid tumor may be said to present 
quite the appearance and behavior of an ordinary mucous mem- 
brane abundantly supplied with glands and vessels. Ovarian cysts 
may develop singly or by a number of cysts, though it is claimed 
that the appearance of single development is not real, but that on 
account of the number of cysts of all sizes in a common sac, they 
may have the appearance of a solid mass. Should it occur, how- 
ever, that the fluid is contained within a single sac, it is known as 
a multilocular, or compound cyst — a proligerous cyst, or a poly- 
cystic tumor. I prefer the term unilocular to express the simple, or 



1) Winckel, Op. Cit., p. 523. 



TRUE CYSTS OF TEE OVARY. 325 

essentially single cyst, and multilocular for the compound, or tumor 
formed from many cysts. 

Ovarian cysts may consist of large unilocular or multilocular 
cysts, from the size of a man's head to that of the uterus at the 
ninth month of pregnancy, and containing from fifty to one hun- 
dred quarts of fluid. They may occur in one or both ovaries. 
According to Kindfleisch all cystic tumors are multilocular in the 
beginning, and become unilocular by fusion of adjacent cysts by 
the breaking down of the dividing septa, and by the further devel- 
opment of the cystic wall. The tumor is attached to the uterus 
by means of a pedicle, in which are to be found the ovarian liga- 
ment, the Fallopian tube, and the two folds of the broad ligament, 
with the intervening connective tissue, containing numerous vessels, 
which are sometimes very large. Occasionally there is no pedicle, 
the tumor being directly connected to and resting upon the uterus 
by a broad base. u The components of the cystoma are the main 
cystic walls, the secondary cysts, the proliferations of the inner 
and external surface, and the cystic contents, generally fluid. 

w4 The main cystic Avail, inclosing all the other structures, 
forms the external boundary of the tumor, and usually incloses a 
main cystic space, which has always been formed, perhaps, by a 
confluence of several smaller primary cysts, and from its wall stand 
most of the glandular and papillary vegetations, and it also conceals 
the principal mass of the contents. The older the cystoma, the 
larger in general becomes the principal cystic space, and finally 
the cystoma becomes unilocular, all the secondary cysts being- 
blended with the chief cyst. 

"The principal cystic walls, and the walls of the somewhat 
larger secondary cysts, consist of two layers, an external connect- 
ive tissue stratum, rather dense, of parallel fibres, and a much 
thinner stratum, very well provided with cells and vessels, on which 
the epithelium immediately sits. The smaller^ cysts are sur- 
rounded only by the last mentioned stratum." (1) 

The contents of ovarian cysts vary between a clear, albumin- 
ous serous fluid, and a thick gelatinous material. The specific 
gravity is usually about 1018 or 1020, but may be much lower. 
The most important chemical constituent is an albuminate termed 
by Eischwald colloid. He claims that this colloid material changes 
into muco-peptone, while the albuminates transuding from the 
blood are converted into albumino-peptone. Paralbumin is invar- 
iably present, which is proved by the fluid becoming cloudy when 
boiled with dilute acetic acid. When no paralbumin is present the 
solution above the sediment becomes clear mucin, being insoluble 
in dilute acetic acid. As paralbumin is found in ascitic fluid and 

1) Emmett, Prin. & Pract. of Gyneology. p. 665. 



326 A TEXT-BOOK OF GYNECOLOGY. 

in the urine, too much significance must not be attached to its 
presence. The invariable presence of albumin in ovarian fluid is 
of the utmost importance from a diagnostic standpoint, and while 
cases have been known in which heat and nitric acid failed to pre- 
cipitate albumin, nevertheless it is usually considered that all true 
ovarian fluids contain albumin. Ovarian fluid does not give a 
flocculent precipitate, as ascitic fluid does. 

The corpuscular elements of ovarian fluids are various. There 
may be oil globules, cholesterine crystals, blood, fresh or altered 
with large granular cells. 

The presence of a pathognomonic ovarian cell has been advo- 
cated by Hughes, Bennett and Drysdale, which, according to Drys- 
dale, "is generally round, delicate, transparent, and contains a 
number of granules, but no nucleus. Its size varies from ^ w 
to z l m of an inch in diameter. That these cells are usually patho- 
gnomonic of ovarian cysts has not yet been verified. 

Ovarian cysts are subject to retrograde metamorphosis, the 
method of which is described by Waldeyer as follows: — 

1. The fatty degeneration of the epithelial cells and the cells 
of the connective tissue parietal stratum, which rarely appears to 
any great extent. 

2. The sclerotic condensations of the connective tissue in the 
principal cystic walls. 

3. The wasting away of the cysts, proceeding from the de- 
struction of all the secondary cysts and the atrophy of the glandular 
formations of the inner cystic wall and its epithelium, with which 
ceases all power of proliferation, and all secretion of the cystoma, 
the latter then remaining stationary. This process, only observed 
in the grandular cystomata, is the consequence of the pressure that 
the constantly accumulating cystic contents exercise in a certain 
toughness and unyielding condition of the walls. 

4. Hemorrhages in the interior take place pre-eminently in 
papillary cystomata from the very vascular papillary proliferations. 

5. The acute purulent inflammations start from the inner 
parietal layer of the cystoma, which is well provided w T ith cells. 
The abundance of the cells is then so increased that all the fibrous 
elements among them disappear, the vessels are dilated and contain 
colorless blood-corpuscles in large number. In places here and 
there, the epithelium in large tracts is detached from the wall of 
the cyst by the pus cells breaking through it; the pus pervades 
this epithelium and accumulates on its side, so that the epithelium 
is bathed by the pus on both sides. At the point where the 
epithelium is detached from its substratum vascular loops soon 
sprout up. 

6. The spontaneous perforations of the cystic wall either 



TRUE CYSTS OF THE OVARY, 327 

originate through extended fatty metamorphosis, or the cause is 
to be found in extensive papillary proliferations of suppurations, 
gangrenous disintegration. 

To these should be added the process of calcification which 
sometimes takes place. This is usually slight in extent, but in 
exceptional cases may comprise the whole cyst, forming a bony 
capsule as thick as that of the human calvarium. 



CHAPTER XLIL 

ETIOLOGY, NATURAL HISTORY, AND SYMPTOMS OF OVARIAN 

CYSTS. 

Little is definitely known as to the cause of ovarian cysts. 
Some authors claim that they are always of congenital origin, as 
cysts have been repeatedly found during foetal life. As we have 
already seen, the congenital character of dermoid cysts Las been 
pretty well established, and there is no reason why other cystic 
growths may not have a similar origin. If so, as a rule they do 
not begin to develop until after puberty, during the period of 
ovarian activity. A limited number of cases have been observed 
during childhood, the ratio of frequency increasing until it reaches 
its height between the thirtieth and the fortieth year, and then 
gradually decreasing. Cases are met with after the menopause, 
and occasionally at a late age. The exercise or non-exercise of 
the sexual functions has no influence whatever in the production 
of ovarian cysts. Heredity is supposed by some authors to be an 
important cause, but this has not been sufficiently verified for 
general acceptance. According to Thomas, (1) " nothing can with 
safety be assumed beyond this, that it is probable that those influ- 
ences which keep up and intensify ovarian congestion and interfere 
with rupture of the follicles of DeGraaf, tend to produce cystic 
and follicular degeneration. Kiwisch, Rokitansky, and Rindfleisch, 
all agree in thinking it probable that inflammation affecting the wall 
of the vesicle has an influence on the production of the disease. " 

Natural History. — The natural course of an ovarian cyst is 
to grow rapidly, and, in about two years from the time of its dis- 
covery, to destroy life by exhaustion through the embarrassing 
pressure which it makes upon the organs of respiration, circulation 
and nutrition. In very rare instances ovarian cysts have for some 
unknown reason ceased to grow, and remained stationary for many 
years, but this is very exceptional. Unilocular cysts grow more 
slowly than multilocular cysts. The average time for the latter 
is about a year, and for the former from one and a half to two 
years from its discovery. 

Dr. Peaslee (2) has conveniently divided the development of 
an ovarian tumor in the following maimer: — 

1) Diseases of Women, p. 673. 

2) "Ovarian Tumors, their Pathology, Diagnosis, and Treatment, etc., ,, by E. Randolph 
Peaslee, M.D.. LL.D. 328 



OVARIAN CYSTS. 329 

"First stage. The cyst is still within the pelvis/* 

* * Second stage. The upper extremity of the tumor has risen 
out of the pelvis, and is extending to the level of the umbilicus." 

• ' Third stage includes the growth upward from the umbilicus 
to the epigastrium. " 

** Fourth and last stage is that in which the growth of the 
tumor is such as to increase its prominence and circumference 
alone, it having risen in the preceding stage to its highest point." 

• * It is also convenient to speak of the middle of the second 
stage, the tumor reaching half way from the symphysis pubis to 
the umbilicus, and the middle of the third stage, when it has 
attained to the point midway from the umbilicus to the ensiform 
cartilage." 

Cases of spontaneous disappearance of ovarian cysts are on 
record, but many authors believe it to be impossible for such a 
thing to occur, without surgical or accidental help. 

Ascites may exist concurrently with an ovarian cyst, and this 
is more apt to be the case where the tumor is undergoing can- 
cerous degeneration. Dr. Goodell (1) says that "this can usually 
be detected by deep palpation, when the cyst will be reached and 
recognized by the fingers: or by pressing lightly, and then more 
firmly during percussion, an upper and a lower stratum of fluctua- 
tion will be detected." 

Sometimes cysts become inflamed, and this may lead to the 
formation of pus. or the secretion of a foul fluid, or it may extend 
to the peritoneum, giving rise to a general peritonitis. If the 
former, the pus or fluids may become absorbed and a fatal pyaemia 
or septicaemia result, or by rupture of the cyst they may be dis- 
charged into the peritoneal cavity and set up a rapidly fatal 
peritonitis. Occasionally the pedicle becomes twisted, causing 
obstruction of the blood supply and preventing the return of the 
blood from the tumor. This may result in gangrene, or, less often, 
in a hemorrhage into the cyst, either of which will result fatally 
unless the tumor be promptly removed. Sometimes the twisting- 
takes place very gradually, and when so the pedicle may gradually 
atrophy, allowing the tumor to finally become separated from its 
attachments and be free in the cavity of the abdomen. 

Ulceration of the cyst wall may occur, and this, resulting in 
perforation, allow the cyst contents to be discharged into the peri- 
toneal cavity, or into any organ to which the tumor may have 
become attached. In this way the cyst contents may escape through 
the intestines, the bladder, the vagina, or even through the Fallo- 
pian tubes and the uterus. 

In some instances hemorrhage takes place within the sac. If 



1) Pepper's System of Medicine, p. 306. 



330 A TEXT-BOOK OF GYNECOLOGY. 

so, the tumor rapidly enlarges, there is great abdominal pain, and 
symptoms of loss of blood. Death may result within a few hours, 
from the hemorrhage directly, or later from septicaemia, the result 
of the decomposition of the now bloody fluid. In such cases the 
tumor should be removed at once, as the patient's only chance of 
life. 

The course of an ovarian cyst is liable to be complicated by 
either of the following conditions: — Pregnancy; ascites; peritonitis; 
Bright's disease; gastritis; septicaemia; fecal impaction; diarrhea; 
hernia. 

Thomas gives the following resume of the methods by which 
ovarian cysts produce the usual fatal results when not interfered 
with by surgical means (1): — 

1 . "A cyst may rupture and produce peritonitis, either before 
or after suppurative inflammation of its walls. 

2. "Inflammation of the cyst wall may result in the filling 
of the cyst with pus, which produces hectic and in time exhaustion 
and death. 

3. kt Fatal hemorrhage may occur in the cyst. 

4. " Prolonged interference with the functions of nutrition 
and respiration may sap the powers of life. 

5. " Death of the cyst may occur from twisting or rupture 
of the pedicle and cause septicaemia. 

6. "A low grade of gastritis, pleuritis, or enteritis may 
produce exhaustion. 

7. " Finally, from the combined depreciating influences of 
this condition, gradual or sudden prostration of strength may close 

' the scene by death." 

Symptoms. — The symptoms of an ovarian cyst, especially in 
the first stage, are quite variable. Generally the symptoms during 
the first stage are so trivial that they do not receive the attention 
of the patient, and it is only after the second stage has set in that 
she becomes suspicious and consults a physician. Indeed, ovarian 
cysts are often well advanced in the third stage, especially in 
elderly women, before especial complaint is made, or it is thought 
necessary to seek professional advice. Menstrual irregularities 
are sometimes present during the first stage, but this is not the 
rule. If both ovaries are affected, there may be a suppression of 
the menses, though this is not invariable. On the other hand, 
when only one ovary is affected, alterations both in the character 
and amount of the menstrual discharge may be noticed, and the 
flow may be entirely suppressed. In such instances the condition 
is often mistaken for pregnancy, and a physician not consulted 



1) Op. Cit., p. 677. 



OVARIAN CYSTS. 331 

until the case is already in the fourth stage. Sometimes, though 
rarely, dysmenorrhea is a constant symptom. In fact, menstrua- 
tion presents no pathognomonic symptoms dependent upon an 
ovarian cyst. 

Frequently no symptoms whatever are manifest until the 
tumor becomes large enough to press upon the rectum and blad- 
der, giving rise to constipation or dysuria, or both. The former 
does not always result from pressure, but sometimes arises from 
reflex causes, from lack of exercise, and sometimes because the 
patient avoids defecation on account of the pain produced from 
straining when the tumor is sensitive, or where pelvic peritonitis 
is present. 

The patient may also complain of weight in the pelvis, pain 
in the back and abdomen, pain and lameness in the legs, weari- 
ness on slight exertion and coldness of the feet. The pain and 
lameness are most frequently confined to one leg. 

As the tumor continues to enlarge and approaches the third 
stage, the patient begins to complain of a sense of distension, 
especially if she has not borne children, and the abdominal 
parietes do not readily yield to the expanding tumor. At the 
same time dyspnoea begins to show itself, the tumor having begun 
to encroach upon the diaphragm, compressing the lungs and dis- 
placing the heart, while oedema of the vulva and extremities, and 
other evidences of venous obstruction, are also manifest. 

The appetite and digestion remain unimpaired during the 
early stages, yet the patient looks pale and careworn, and evi- 
dences of beginning malnutrition are already becoming manifest. 
Emaciation gradually sets in, and finally the fades ovariana, so- 
called, the characteristics of which are prominent cheek bones, 
sharp nose, clearly defined alee nasi, firmly closed lips, corners of 
the mouth depressed, and furrows about the mouth and upon the 
forehead. Should inflammation set in, these symptoms are especially 
marked. Occasionally the usual mammary and gastric symptoms 
of pregnancy are present, but this is not common. 

Sterility is usually, though not necessarily, present, concep- 
tion having been known to occur when both ovaries were diseased, 
evidence that healthy follicles still remained. Sterility is not 
always due to the fact that the ovary is diseased, but sometimes 
results from pressure upon the tube, or uterine displacement, 
menstrual anomalies, etc. 

Thomas (1) gives the following summary of the symptoms 
of an ovarian cyst from the commencement of its growth to its 
full development: — 

1) Op. Cit,, p. 682. 



332 A TEXT-BOOK OF GYNECOLOGY. 

u Irritability of the bladder, dysmenorrhea, constipation, 
hemorrhoids, pelvic pains of neuralgic character, symptoms of 
pregnancy, scanty urinary secretion, intestinal and digestive dis- 
order, deranged respiratory function, peculiar facies, emaciation, 
oedema, venous distension of surface, ascites," vomiting, diarrhea, 
cardiac irregularity, aphthous stomatitis, and hectic. In cases 
advanced in the last stage, all the last of these may show them- 
selves, and in early cases all the first mentioned; but, in many 
instances, some of the most prominent of these signs are entirely 
wanting. 1 ' 



CHAPTER XLIII. 



DIAGNOSIS OF OVARIAN CYSTS. 



The objective symptoms or physical signs of ovarian cysts 
are by far the most important for diagnostic purposes. For this 
reason, and to avoid repetition, these will be considered under the 
head of diagnosis. 

Too much care cannot be taken in making the examination 
for suspected ovarian cyst. While the majority of cases are 
comparatively easy of diagnosis, yet there are numerous excep- 
tional cases, where the diagnosis is beset with difficulties, and 
humiliation may only be avoided by a thorough and careful 
exploration. When we realize that such blunders have been 
made by some of the most distinguished surgeons in the world, 
we can appreciate the importance of being able to distinguish an 
ovarian cyst from other tumors or other fluid collections in the 
abdominal cavity. 

The methods of physical examination are: — inspection; 
mensuration; palpation; percussion; auscultation; vaginal and 
rectal touch; the chemical and microscopical examination of the 
cyst fluids; explorative incision. 

The patient should be placed upon the back, the abdomen 
uncovered, all constriction removed from the waist, and the knees 
drawn up so as to relax the abdominal muscles. In case the 
patient, from nervousness or from a desire to mislead, persistently 
contracts the abdominal walls, it may be necessary to use an 
anesthetic in order to produce complete relaxation. 

If the tumor is in the first stage, still lying within the pelvis, 
neither inspection, palpation, percussion nor auscultation are of any 
avail, but a vaginal examination finds the cervix displaced to the 
side opposite that of the tumor, and through the fornix a tense, 
round, fluctuating mass is felt, projecting downward. Bi-manually 
the uterus is felt displaced to one side, and distinct from the 
tumor, which can usually be mapped out between the hands. 
Should the tumor lie posterior to the uterus, as is most often the 
case, bi-manual examination will reveal the uterus markedly dis- 
placed to the front, but normal in size, while bulging downward 
behind the cervix the round, globular, cystic ovary is found. 

In the first stage an ovarian cyst is most liable to be mistaken 
for pelvic cellulitis, cyst of the broad ligament, hydrosalpinx, 

333 



334 A TEXT-BOOK OF GYNECOLOGY. 

tubal pregnancy, pelvic peritonitis, fibroid, retro-uterine hema- 
tocele, and fibro-cystic tumors of the uterus. 

Pelvic Cellulitis. — Here there is almost always a history 
of inflammation, following some probable cause — abortion or 
parturition. If the inflammation has gone on to suppuration, 
there will be rigors, etc. If cellulitic deposits have taken place 
they are always fixed, unless occurring within the broad liga- 
ments, and they give no sense of fluctuation, except very feebly 
when purulent matter is present. 

Pelvic Peritonitis. — Here, too, there is a history of inflam- 
mation, and aspiration yields serum, and not ovarian fluid. The 
latter is the most important diagnostic feature, and where periton- 
itic adhesions are present it is almost invariably required. 

Cysts of the Broad Ligament. — These are not so rounded, 
and have very distinct fluctuation; their secretion is usually 
simple salt water, and when tapped they do not recur. 

Hydrosalpinx. — This lies high in the pelvis, and instead of 
presenting a round, globular tumor, it is tortuous, and elongated 
from side to side. 

Tubal Pregnancy. — The sac may be distinctly recognized as 
being to the side of the uterus, and frequently ballottement can be 
obtained as early as the second or third month. In very obscure 
cases a little fluid may be drawn off with the aspirator, but this 
must be done with great care. 

Retro-Uterine Hematocele. — If the history of sudden 
onset and excruciating pain are not sufficient, the finger will de- 
tect the cul-de-sac filled as with a fluid which had settled down 
into it, while cystic growth preserves its outline, which can be 
traced beyond the sac in which it rests. 

Fibroid Tumors of the Uterus. — The tumor cannot be 
separated so as to become distinct from the uterus; it is more 
solid and mobile in character, and always more consentaneous with 
any movement of the uterus. The sound shows an increased 
depth of the uterus, and uterine hemorrhages are of more or less 
frequent occurrence. 

Fibro-Cystic Tumors of the Uterus. — These are most 
difficult to differentiate from an ovarian cyst, and indeed most 
authors consider the diagnosis impossible without an explorative 
incision. In all cases in which the ovarian tumor continues to retain 
its pelvic position, it is liable to give rise to pelvic inflammations 
which complicate the diagnosis, and render it necessary to aspirate 
before a positive opinion can be given. After the tumor is in 
the second or third stage, having reached the umbilicus or 
epigastrium, the subsequent physical signs are correspondingly 
more distinct and positive in their character. 



DIAGNOSIS OF OVARIAN CYSTS. 335 

On inspection the abdomen is seen to be greatly distended. 
The distension may be uniform but it is often more or less lateral, 
and there occurs but very little flattening out by the sagging of 
the fluid to the flanks, as in ascites, thus showing that the fluid is 
encysted. When there are but two or three large sacs, the lines 
which separate them may sometimes be easily recognized, and the 
sulci between the solid and the cystic portions are sometimes quite 
plainly marked. The superficial abdominal veins may be dilated, 
and linea albicantes are sometimes present. 

Mensuration should be practised from the xiphoid cartilage to 
the umbilicus, and from the umbilicus to the anterior spinous pro- 
cesses of the ileum. If there be an ovarian cyst, this measure- 
ment will show a marked difference between the tAvo sides if it is 
unilocular, and less difference if it is multilocular. The measure- 
ment should also be taken from the umbilicus to the upper margin 
of the symphysis pubis, and if this measurement exceeds that 
from the xiphoid cartilage to the umbilicus, and the tumor is fully 
developed, the tumor is uterine and not ovarian. 

Palpation reveals a firm, dense, and sometimes angular or 
lobulated mass, which yields fluctuation. But the fluctuation is not 
of the soft, superficial character that we get in ascites, for it gives 
to the touch the sensation of a firm sac filled with fluid, thus ren- 
dering the fluctuation less distinct, and the mass more resisting. 
If the fluctuation be very obscure, the bi-manual, and the vaginal 
or rectal touch, are necessary to establish it. 

Percussion yields dullness over the tumor, and in one flank, but 
at the flank where the tumor does not bulge it is clear and tympanitic, 
this condition remaining notwithstanding any change in posture 
the patient may assume. This shows that the fluid is encysted. 

Auscultation is of little value, save that it serves to exclude 
pregnancy. Vaginal touch shows the uterus to be displaced to 
one side or forward, rarely retroverted. and never enlarged unless 
impregnated. At the same time the lower surface of the tumor 
may be felt, and obscure fluctuation elicited. Rectal touch may 
be accomplished with the index finger after first drawing down 
the uterus with a volsella. In this way the border of the uterus 
may be felt, and from its angle a tense band, — the pedicle of the 
tumor, — passing out to the cyst. This examination is more read- 
ily made in the genu-pectoral position. Winckel and others rec- 
ommend the use of two fingers only, having abandoned Simon's 
method as somewhat dangerous, and because it furnishes less in- 
formation than an examination by two fingers. 

In obscure cases the nature of the cyst contents may be de- 
termined by drawing off a specimen by use of an aspirator or a 
small trocar, the use of the aspirator being much the safer method. 



336 A TEXT-BOOK OF GYNECOLOGY. 

Should these methods not prove sufficient for diagnostic pur- 
poses, the last resort is an explorative incision, which is necessarily 
attended by some danger. 

The conditions with which an ovarian cyst in its later stages, 
is most likely to be confounded are : Obesity; pregnancy and 
hydramnios; extra-uterine pregnancy; ascites; phantom tumor; en- 
cysted peritoneal dropsy; uterine fibroids, and fibro-cysts; par- 
ovarian tumors; renal tumors; floating kidney; distended bladder; 
pelvic hematocele; hypertrophy of the liver and spleen. Each of 
these conditions must be considered, and their presence either ex- 
cluded, or established as a complication, before a positive diagnosis 
can be arrived at. 

Obesity. — This is sometimes mistaken for an ovarian cyst, 
but the accumulation of fat is never entirely confined to the abdo- 
men, for the breasts, face and limbs partake of the general enlarge- 
ment. When assuming the sitting posture the fat hangs in folds 
over the abdomen, and the umbilicus is indented, and not protuber- 
ant as in ovarian cyst. Usually the fat can be grasped in the hand 
and its superficial character determined. 

Pregnancy. — This condition is usually readily distinguished 
from an ovarian cyst, though this is not always the case, for the 
diagnosis is in some instances very difficult. Ordinarily the 
history of the case will be of great aid, but sometimes it is entirely 
misleading, either accidentally or intentionally, and the diagnosis 
must be based entirely upon the results of a physical examination. 
The gastric, mammary and nervous symptoms of pregnancy are 
of great importance, yet it should be remembered that these some- 
times result from ovarian disease. Should the circumstances seem 
doubtful and the diagnosis difficult, there can be no necessity for 
operative procedures until time shall have so developed the con- 
dition that if pregnancy exists the foetal body and its movements 
may be detected by palpation, and the foetal heart-sounds and 
placental bruit be obtained by auscultation. The vagina is dark in 
color, the mucous secretion increased, and the cervix soft. The 
sound should not be employed. In case the child is dead, the 
history of the case, rectal exploration, and dilatation of the cervix, 
with subsequent digital examination, will usually be sufficient to 
establish the fact. 

Hydramnios. — An undue accumulation of the amniotic fluid 
causes a pregnant uterus, when examined only through the abdo- 
men, to resemble very closely a large unilocular cyst, but if the 
history of the case is carefully weighed, it is only in its too rapid 
increase, and in the undue preponderance of its fluid contents, 
that the uterine swelling differs from what is normal in pregnancy. 
The physical characters of the lower segment of the uterus are 






DIAGNOSIS OF OVARIAN CYSTS. 



337 



those of advanced pregnancy, and the whole history points in the 
same direction. Here the patient is always of an hysterical tem- 
perament, and the great danger is that she may so closely imitate 
the symptoms of pregnancy as to sadly perplex the physician. 

In phantom tumors all the usual results of auscultation and 
percussion in ovarian cysts are wanting, and frequently steady 
pressure during deep inspiration will cause the tumor to entirely 
disappear. In very doubtful cases an anaesthetic should be admin- 
istered, which will allow a free bi-manual examination, and remove 
all possible doubts. 

Ascites. — In cases in which the abdomen is greatly distended 
there may be considerable difficulty in differentiating ovarian cysts 
from ascites. In ascites, however, there is always a history of 
some previous organic disease of either the heart, lungs, liver, 
kidneys or peritoneum. Usually, too, there is more or less oedema 
of the face and lower extremities, and the abdominal enlargement 
increases much more rapidly than in ovarian cysts. The most im- 
portant diagnostic symptom is the tendency of the free ascitic 
fluid to go to the most dependent portions of the body, so that a 
change in position changes the location of the fluid, the position 





.Fig. 185. — The shaded portion shows the dull area; left figure — ovarian 
tumor; right figure — ascites (Barnes). 

of which can be readily ascertained by percussion. When 
the patient lies upon her back the intestines float to the sur- 
face and the fluid gravitates to the flanks, making them bulge, 
and percussion gives a tympanitic sound at the umbilicus, and a 
dull sound at the flanks; when on her left side the dullness is con- 



338 A TEXT-BOOK OF GYNECOLOGY. 

fined to the left side, and when on her right the dullness is trans- 
ferred to the right side, the opposite side giving a clear note. 
When sitting up, the upper limit of the dullness is curved, with 
the convexity downward. In ovarian cysts the contour of the 
tumor remains the same regardless of position, and likewise does 
percussion always yield about the same results. In doubtful 
cases some of the fluid may be drawn off by aspiration and 
examined, or the patient may be tapped, and then the solid con- 
tents of the cyst, if it be one, be readily grasped by the hand and 
its character and location ascertained. 

Encysted Peritoneal Dropsy. — Here the previous history, 
as pointing to peritonitis, tuberculosis, or cancer, is of the greatest 
importance. "The physical signs of this limited dropsy are 
precisely the same as those of ovarian dropsy. But the former is 
always either traumatic or malignant, has no necessary connection, 
is almost always central from the first, grows more rapidly, is not 
usually accompanied by a marked emaciation and failure of the 
general health, and almost always disappears with one or two 
tappings by the exploratory incision, or from a spontaneous rup- 
ture of the extemporized sac. Usually, but not invariably, the 
contained fluid is very thin and of a light color, with an absence of 
the physical qualities of the ovarian cyst-fluid. This is the kind of 
'ovarian tumor,' which is sometimes cured by electricity, massage, 
or by internal medication, when, in reality, it is not an ovarian 
tumor at all, but a kind of sacculated dropsy that is common to 
men and women alike." (1) 

Uterine Fibroids. — Usually there is but very little difficulty 
in differentiating between an ovarian cyst and a fibroid tumor of 
the uterus. If, however, the latter be large and of the soft variety, 
it may give an obscure sense of fluctuation that will prove mis- 
leading. But usually the well-defined outline of the fibroid, its 
firm, solid consistence, its intimate connection with the uterus, the 
increased depth of the latter, the frequent uterine hemorrhages, 
the uterine souffle, and the comparatively slow growth of a fibroid, 
are sufficient evidences of the character of the growth to make its 
diagnosis easy. If, however, the fibroid is of the sub-serous variety, 
with a pedicle, there may be greater difficulty; or, on the other 
hand, should an ovarian cyst have a close attachment to the uterus, 
the latter may become elongated, and also follow the movements 
communicated to the tumor. 

Uterine Fibro-Cysts. — A positive diagnosis between an 
ovarian cyst and a fibro-cystic tumor of the uterus is considered 
impossible, but fortunately the latter are of extremely rare occur- 
rence. In uterine fibro-cysts the fluctuation is only partial, and 

1) Ludlam. Arndt's System of Medicine, Vol. II, p. 353. 



DIAGNOSIS OF OVARIAN CYSTS. 339 

the continuance is variable; the rate of growth is slower, there is 
usually an intimate connection with the uterus, and the fluid drawn 
off quickly and spontaneously coagulates, which the fluid of an 
ovarian cyst never does. 

Kenal Tumors. — A renal cyst usually occupies the lumbar 
region, and as it extends downward and forward always pushes 
the intestines before it, and does not in any degree impinge upon 
the vaginal cavity. Its growth is generally slow, and usually 
associated with evidences of organic disease of the kidneys. Aspira- 
tion gives a clear limpid fluid, in which urea or uric acid are almost 
always present. 

Floating Kidney. — These are attached so that they cannot 
be crowded low into the pelvis, as can an ovarian cyst of a like 
size. The floating kidney also retains its peculiar shape, and often 
during examination will slip from the fingers back to its normal 
position in the flank and thus elude further search. 

Distended Bladder. — This may be recognized by its peculiar 
bulging form, and is of course readily emptied by the introduction 
of the catheter. 

Pelvic Hematocele. — The diagnosis here would only be 
difficult in the case of a small ovarian cyst, lying within the 
pelvis and complicated with inflammation, which has already 
been referred to. 

Hypertrophy of the Liver and Spleen. — In each of these 
conditions the constitutional symptoms, or evidences of chronic 
disease, are important. So, also, in the fact of their location or 
point of development. They both grow from above downward, 
and their independence from the pelvic organs can be usually easily 
ascertained by a careful bi-manual or rectal examination. 

Adhesions. — The diagnosis of adhesions is not considered of 
so much importance as formerly, but these may be especially 
serious if the attachments are to the bladder or to the tissues deep 
in Douglas' pouch, and ought to be diagnosticated in advance, 
though anything more than a general surmise is hardly possible. 

Usually, however, if there are adhesions, there has been a 
history of inflammation, and the course of the tumor growth has 
been marked with more or less pain. If there has been no pain, 
and the tumor seems movable, and especially if its growth has 
been rapid, and it presents the appearance of a unilocular cyst, 
there are probably no adhesions, but there can be no positive 
certainty upon that point. 

It is always desirable to find the length of the pedicle, but 
this cannot always be done. Thomas finds the following rule 
to be very valuable for this purpose: — "If the tumor be found far 
up, out of the pelvis, upon vaginal examination the pedicle cannot 



340 A TEXT-BOOK OF GYNECOLOGY. 

be very short. If a tumor which is not very large be fixed in the 
pelvis so that it cannot be pushed out, the pedicle is probably a 
short one." (1) 

Other rules have been laid down which are probably of more 
or less value in approximating the length of the pedicle, but I 
think the above is about the only rule that receives the practical 
attention of gynecologists. 

1) Thomas, Op. Cit., p. 698. 



CHAPTER XLIV. 



TREATMENT OF OVARIAN CYSTIC TUMORS. 

Medicinal. Surgical. Tapping. Injection of Iodine. Drainage. 

Incision. 

Medicinal Treatment. — While it is a well established fact, 
that a true ovarian cyst is not, as a rule, amenable to medical 
treatment, nevertheless homeopathic literature furnishes reports of 
several cases treated by intelligent representatives of homeopathy, 
wherein it is claimed that ovarian cysts have been cured solely by 
the administration of the indicated remedy. Dr. Lucllam, in his 
valuable article on Ovarian Tumors appearing in Arndt's System 
of Medicine, has carefully collected most of these reports, which 
I take the liberty of here reproducing: 

"Apis Mellifica. — In a paper read before the Pennsylvania 
State Homeopathic Medical Society, Oct., 1877, Dr. H. N. 
Guernsey says: w In Raue's Annual Record for 1870, page 70, is 
the first case on record, so far as I know, and it was a cure effected 
by myself nearly twenty years ago. This case came into my 
hands after it was pronounced by several of our best allopathic 
physicians and surgeons to be a well-developed instance of ovarian 
dropsy, which nothing but the knife would relieve. The fear of 
so formidable an operation induced her to seek my aid. The 
tumor w r as so large as to fill the entire abdominal cavity, rendering 
stooping impossible. There was also an anasarcous condition of 
the cellular tissues throughout the whole body. The character- 
istic symptoms indicating the remedy were pains like bee-stings in 
the ovarian cyst, very scanty urine and no thirst. By administer- 
ing Apis mel., in strict conformity with our law of cure, in the 
course of ten months she was restored to perfect health. A few 
months after the cure she was found to be pregnant, and in due 
time gave birth to a healthy child.' 

' ' Other cases believed to have been cured by the same remedy 
are reported by Dr. A. E. Small (Raue's Record, 1873, p. 173); 
Dr. P. H. Hale (Raue's Record for 1872, p. 173); Dr. A. M. 
Piersons (N. A. Journal of Horn., xxi, p. 553); Dr. C. Wessel- 
hoeft (Hahnemanian Monthly, ii, p. 18±); Dr. J. H. Payne (ibid., 
p. 50); and by Dr. William Tod Helmuth (Trans. World's 
Homeopathic Convention, vol. ii, p. 675). 



342 A TEXT-BOOK OF GYNECOLOGY, 

"Belladonna. — Dr. H. N. Guernsey (Hahn. Monthly, Dec., 
1887,) says: 'Another marked case comes to my mind, which I 
cured several years ago. The tumor was as large as the head of 
a new-born child at full term, situated in the right ovarian region, 
and was caused by falling over a wash-tub. There was pain at 
every menstrual period, terrible forcing and bearing down, as 
though everything would issue at the vulva. This case was cured 
perfectly and completely after six months, by Belladonna given 
at every menstrual period.' 

"Calcarea Carbonica. — Dr. Charles Sumner {Trans. N. Y. 
Horn. Med. Society, vol. ix, p. 312) cites a cure with this remedy 
in the sixth potency, the patient having taken it for the space of 
one year; and Dr. Guernsey (op. citat.), another in which the 
Calcarea carb. was followed by Sepia with a perfect result. 

"Colocynth. — With his accustomed caution, the late Dr. 
Carroll Dunham (W. England Med. Gazette, vol. iv, p. 311) 
reports a case that dates to Oct. 10, 1864, as cured by this remedy. 
But the diagnosis was faulty, and he evidently felt it to be so, for 
he closes his report with the suggestive inquiry, ' Was this really 
an ovarian tumor ? ' 

"Graphites. — Dr. R. E. Dudgeon {British Journal of 
Homeopathy, 1873, p. 187) reports a case of this kind cured by 
Graphites. 

"Kali Bromidum. — Dr. Richard Hughes, in the same journal 
for 1872, p. 793, cites a cure of ovarian dropsy by this prepara- 
tion of Kali. Afterward the abdomen seemed filled with fluid, 
which was entirely removed by Apocynum, Arsenium, and Apis 
mellifica. But the innocuous character of this fluid is pretty good 
proof that the case must either have been one of encysted peri- 
toneal dropsy, or a cyst of the broad ligament, both of which have 
been many times mistaken for ovarian dropsy. 

"Platina. — Much stress has been laid by some physicians 
upon Dr. Mercy B. Jackson's reported cures with this remedy. 
The reader will find the three cases in the North American Journal 
of Homeopathy for Aug., 1873, at p. 90. The doctor does not 
claim that they were cases of ovarian dropsy, and evidently they 
were not. 

"Podophyllum Peltatum. — In the year 1857, and again 
in 1869, Dr. William Gallupe reported to the American Institute 
{vide Trans, for those years) the cure of two ovarian tumors, the 
first in the right side, and the second in the left one, in which the 
persistent use of this remedy seemed effectual." 

Dr. Ludlam then remarks that "Other cures of ovarian 
tumors by internal medication are reported in our periodical litera- 
ture; but in most of them it is not stated whether the tumors were 



TREATMENT OF OVARIAN CYSTS. 3-13 

cystic, solid, or composite; many of them were treated years ago, 
when the means of diagnosis were much less perfect than at the 
present time; and in many of them so much time was consumed 
in the treatment, and so many remedies were given, one after 
another, as to render them of little value. Perhaps the most 
remarkable cure of this kind is that furnished by Dr. J. G. Bald- 
win (HelmutJCs Surgery, 3d edition, p. 919), in which the tumor 
occurred during two successive pregnancies, was thrice tapped, and 
finally disappeared under Iodine.'''' 

"The fact is, that whatever we may, and really do, accomplish 
in the treatment of ovarian enlargement from other causes than 
cystic degeneration, this special form of disease has not proved as 
amenable to internal medication as we could have desired. The 
therapeutics of genuine, unmistakable ovarian dropsy awaits 
development." 

With this conclusion all unprejudiced persons will certainly 
agree. 

Surgical Treatment. — The various methods for the sur- 
gical treatment of ovarian cysts may be classed as follows: Tap- 
ping; drainage; injection of Iodine; incision; ovariotomy. 

Tapping. — This may be considered a palliative treatment, 
and some authors hold that it should never be resorted to except 
when necessary to obtain fluid for diagnostic purposes. It cures 
parovarian cysts, as these are mere retention cysts. Ovarian cysts 
are not retention cysts, but have a proliferating lining membrane, 
for which reason tapping does not cure them. An additional 
reason against tapping is that it is a procedure by no means free 
from danger, even to life. This danger may arise from suppura- 
tion, sloughing of the cyst, opening of large vessels in the wall of 
the abdomen or tumor, with consequent hemorrhage, and acute 
peritonitis from escape of fluid into the abdominal cavity. These 
dangers may, in a great measure, be avoided by using a suitable 
aspirator with short needles of small calibre, and observing all 
antiseptic precautions, but inflammation may follow the use even 
of the smallest needle, which will compel an immediate resort to 
ovariotomy, and very greatly compromise the success of this radical 
operation. 

Goodell gives the following instances in which tapping cannot 
be dispensed with (1): — 

(1) "Many women with ovarian tumors, having heard of 
cases of abdominal effusion or of cyst in which tapping was followed 
by a cure, will not submit to the radical operation until repeated 
tappings have proved to them the futility of the trocar. 

(2) "Cysts of the parovarium and of the broad ligament 

1) Pepper's System of Medicine, Vol. IV, p. 3C9. 



344 A TEXT-BOOK OF GYNECOLOGY. 

being often cured by the use of the trocar, it is proper to try the 
effect of one tapping in slow-growing, unilocular, thin-walled, 
and flaccid cysts, which thus exhibit the chief characteristics of 
these extra-ovarian cysts. 

(3) ' c When an ovarian cyst develops during the latter months 
of pregnancy, it will often be best to resort to tapping in order to 
relieve the woman from the pressure of two growing organs and 
enable her to go to full term. Sometimes labor is made impossible 
by the presence of a cyst, which will then have to be emptied. 

(4) i ' In very large tumors, which by pressure interfere with 
the functions of the kidneys, heart, and lungs, thereby causing 
albuminuria, oedema, or dyspnoea, tapping is a useful prelude to 
ovariotomy. By the relief from pressure afforded to these organs 
not only will the liability to shock be lessened, but also to hemor- 
rhage, for vessels previouly varicose will now contract to their 
natural calibre. 

(5) u In cases of doubtful diagnosis, or in those in which from 
malignancy, from formidable adhesions, or from other circum- 
stances, the radical operation is deemed impracticable, tapping in 
the first case may clear up the diagnosis, and in the latter ones 
will prolong the patient's life. But it must always be borne in 
mind that in a few weeks the fluid will reaccumulate, and the 
operation will have to be repeated, rapidly exhausting the patient 
by the drain on her system. It is well, therefore, to put off the 
first tapping as long as possible." 

In the operation for tapping Dr. Emmett observes the follow- 
ing rules (1): — "The aspirator should be used, or a trocar longer 
than the one usually employed for ascites. It should always be 
done under the carbolic spray, or with the application of a solution 
of the bichloride of mercury [neither of which are considered neces- 
sary by most operators. — Author], and care should be taken to 
prevent the entrance of air into the sac. As a rule, I prefer to 
place the patient on a narrow couch, and tap while she lies on the 
side. With all other considerations equal, the median line, midway 
between the umbilicus and the pubes, is the safest point for making 
the puncture. Yet if it were ascertained that the main cyst pre- 
sented to either side of the median line, I would puncture at the 
most advantageous point, out of reach of the bladder, colon, and 
stomach. Wherever the point selected, it should be where a 
marked dullness on percussion exists and extends for some distance 
around. 

"Unless a very large trocar is used, it will not be necessary 
to make an incision through the skin, as is usually done on empty- 
ing the abdominal cavity, nor will a bandage be required. 

1) Principles and Practice of Gynecology, p. 689. 



TREATMENT OF OVARIAN CYSTS. 345 

"The requisite support and pressure must be kept up by the 
hands of an assistant, placed at some distance from and below the 
trocar. He should stand behind the patient and carefully steady 
her body as she is rolled over to empty the cyst. The operator 
should seize the relaxed tissues about the trocar between his thumb 
and second finger, and at an inch or more beyond the point of 
puncture. This is done to prevent the contents of the cyst from 
escaping into the abdominal cavity. The patient is then to be 
turned on the back, and the trocar removed while the tissues are 
still grasped. The exit of the instrument can be aided by placing 
the nail of the index finger which is disengaged, against the skin 
at the edge of the puncture. A small piece of adhesive plaster 
should be placed over the puncture, and as the relaxed walls are 
held together, by pressure made on each side with the flat of the 
hand, two broad strips of plaster should be applied from under the 
flank, obliquely across the abdomen, to the neighborhood of the 
false ribs on the opposite side. Unless it is determined to inject 
the cyst, the use of Dieulafoy's aspirator is far preferable for mak- 
ing the first evacuation. The advantage of this instrument is that 
it affords greater immunity from evil consequences if a large viscus 
or blood-vessel is injured, and also entails less danger from periton- 
itis and inflammation of the sac. When the contents of an ovarian 
tumor are too dense to pass through the largest cannula of the 
aspirator, and this is rare, the case will seldom prove a good one 
for tapping. We must not suppose the tumor to be a solid one, 
should no fluid escape, for it is immediately shown not to be solid 
if the cannula can be moved freely in every direction." 

Tapping is sometimes performed through the vagina, but it 
is not as safe as through the abdomen, the greatest danger being 
in the admission of air into the cyst, causing suppurative inflam- 
mation, with all its attendant evils. For this reason this mode of 
tapping should never be resorted to except in cases in which there 
are pelvic adhesions, or when the tumor is so small that it cannot 
be reached by the supra-pubic method. In such cases the aspirator 
should always be used. 

Drainage. — Drainage into the peritoneal cavity, or through 
the vagina, is sometimes practiced. The operation consists merely 
of abdominal or vaginal puncture, and the introduction and reten- 
tion of a tube in the canal thus created by which the fluid passes 
out and injections can be thrown in. The abdominal method is so 
dangerous that it is not to be considered, and the vaginal should 
only be practiced in those cases in which the cyst is immovably 
fixed by adhesions. The thorough washing out of the sac is im- 
portant to guard against blood-poisoning, and to lessen the amount 
of secretion from the lining membrane, thus preventing a serious 



346 A TEXT-BOOK OF GYNECOLOGY. 

drain upon the patient's strength. The hot water employed should, 
from time to time, have added to it proper quantities of tincture 
of Iodine or Carbolic acid. 

Injection of Iodine. — The treatment of ovarian cysts by 
tapping, and the subsequent injections of Iodine into the sac, has 
been practiced and recommended by some gynecologists. One 
author of our own school says (1) that "Iodine injections have 
cured ninety-three per cent, of well selected cases, and about sixty- 
three per cent, of cases taken at random, poly cysts included. Harm 
seems to have resulted in but six instances, though I have collected 
three hundred and eleven cases operated on by different gynecolo- 
gists in this country, Germany, France and England. M. Boinet 
has done more than any other man to demonstrate the great ad- 
vantage of this treatment. Out of these three hundred and 
eleven cases collected I find reported cures in one hundred and 
ninety-seven cases, or about sixty-three per cent., including favor- 
able and unfavorable cases." 

This being the case, it is strange that this method is not more 
widely adopted. In fact, it is seldom practiced, owing to the risks 
and uncertainty attending it. At best it is only applicable in those 
very rare cases where the tumor is large, unilocular and free from 
adhesions. When we remember that the diagnosis in such cases 
is always doubtful, and that in many instances such tumors are not 
ovarian, but parovarian, it is probable that the mere emptying of 
the cyst would do as much good without the possible attendant 
evils of the injection. 

This fact is now admitted by Boinet, and by others, who, like 
him, were once most enthusiastic in the praise of this method of 
treatment. 

The operation consists in emptying the cyst by aspiration, and 
then reversing the action of the instrument, throwing in from two 
to ten ounces of the officinal tincture of Iodine. Some use a trocar 
to empty the cyst, and then make the injection with a syringe, but 
this is a more dangerous method. Allen's surgical pump (Fig. 
54) is decidedly the best instrument to use for this purpose. 

After turning the patient from side to side and kneading the 
abdomen, that the tincture may come into contact with every 
portion of the secreting surface of the cyst, the fluid is pumped 
out. While the needle is being withdrawn, in order to prevent 
the escape of any of the irritating injection into the abdominal 
cavity, the thumb and finger are made to grasp the fold of the 
abdominal wall at the site of the puncture, and to press firmly 
down on the collapsed cyst-wall. 

In some cases of a desperately bad character, according to 

1) Eaton, Diseases of Women, p. 304. 



TREATMENT OF OVARIAN CYSTS. 347 

Thomas, (1) "the multilocular nature of the sac renders tapping, 
drainage, and injection ineffectual for the accomplishment of cure, 
while extensive adhesions bind it to the abdominal walls so firmly 
that extirpation is inadvisable. Under such circumstances the 
operation of incision, which consists simply in laying open the 
tumor by cutting through the abdominal walls, may be resorted to." 

1) Diseases of Women, p. 711. 



CHAPTER XLV. 



OVARIOTOMY. 



Ovariotomy consists in the removal of the diseased ovaries, 
and may be performed either by vaginal or abdominal incision, 
but the former is very rarely employed, the latter being the usual 
method. The history of this important operation is so extensively 
mentioned in most text-books, that I will not occupy space to 
reproduce it further than to say that it was first performed in 
1809, by Dr. Ephraim McDowell, of Kentucky, and notwithstand- 
ing the most violent opposition which it received from the profes- 
sion, it has gradually grown in favor and is now regarded as a 
recognized acquisition to surgery, and though at all times formid- 
able, it, nevertheless, offers a more favorable prognosis than most 
other capital operations. t 

In this connection I cannot resist offering a little advice to 
the many ambitious young men in the profession to-day, who are 
anxiously awaiting an opportunity to perform this apparently 
simple operation. The uncertainty of diagnosis, the probability 
of dangerous adhesions, or of cancerous degeneration, and the 
many serious forms of complication liable to arise after the opera- 
tion, render it at all times, as I have before said, a formidable 
operation, and in the language of a distinguished gynecologist, 
" but few cases are exempt from difficulties, which can only be 
overcome by the largest experience, if at all." Ovariotomy should 
never be attempted by a surgeon who has not already acquired a 
large experience in capital surgery, and who is thus prepared for 
any critical emergency that may arise. 

Ovariotomy should never be performed so long as the tumor 
does not create disturbances which make it necessary. As a rule 
it is confined exclusively to tumors of comparatively large size, 
and after the patient has commenced to emaciate and her health 
begun to fail; but tumors of small size may be removed if they 
cause much suffering. 

When septic peritonitis sets in; when the contents of the sac 
become purulent, as they sometimes do, either spontaneously or 
after an unprotected tapping; when the cyst bursts and serious 
symptoms arise; when torsion of the pedicle occurs, or when a 
free hemorrhage into the sac takes place, the operation should be 
performed without delay. Neither old age nor pregnancy contra- 

348 



OVARIOTOMY. 3-49 

indicates ovariotomy, but it should not be performed when the tu- 
mor is malignant, and the disease has extended to the uterus, 
intestines, or peritoneum, and is no longer limited to the ovary. 
Neither is it admissible when grave, acute or chronic disease is 
present in any of the vital organs, such as cancer, phthisis, or 
Bright's disease. Dr. Ludlam (1) says " valvular lesions of the 
heart must be serious if they are allowed to stand in the way." 
He has several times successfully operated upon patients who were 
afflicted with valvular disease without any serious risk from this 
cause. 

It should be remembered also that albuminuria is often due 
to the pressure of the tumor on the kidneys, and, unless it existed 
before the appearance of the tumor, or is positively known to be 
caused by Bright's disease, should not preclude the operation. 
Gastric ulcer or serious disease of the alimentary canal may con- 
tra-indicate the performance of ovariotomy. Patients suffering 
from extreme exhaustion, the result of the ovarian disease, are less 
likely than those who are in fair condition, to recover from the 
operation; nevertheless, it should be performed, for such cases are 
often saved, even though it would seem that they could not sur- 
vive the anaesthesia. Dr. Ludlam very aptly remarks "that the 
rules governing the choice of suitable subjects for ovariotomy are 
not fixed and unvarying. For, not only have some of the most 
desperate and unpromising cases finally recovered from it, but the 
progress in abdominal surgery is such that the list of contra-indi- 
cations for its employment is shrinking very rapidly. It will 
never be a safe operation when rashly or indiscriminately made, 
but in the hands of an experienced and responsible ovariotomist. 
its range of application and its rate of success are likely to 
increase." 

Vaginal Ovariotomy. — I will describe this method very 
briefly, as it is not of great importance. The patient having 
passed under the anaesthetic, she is placed in a semi-prone, or in 
the lithotomy position. Sims' speculum is passed, and the poste- 
rior vaginal wall behind the cervix is incised along the middle line. 
The tumor is then tapped with an aspirator, and drawn through 
the incision with the finger or curved forceps. The pedicle is then 
ligated with thin carbolized silk, threaded on a handled needle, 
and divided on the side of the ligature next to the tumor. A 
T-shaped drainage tube is then passed into the wound, which may 
be stitched around it, or left open. Should the temperature rise 
or the discharge become fetid, the wound should be daily irrigated 
with a weak solution of carbolic acid. 

Abdominal Ovariotomy. — Having decided upon this opera- 

1) Aradt. Op. Cit.. p. 361. 



350 A TEXT-BOOK OF GYNECOLOGY. 

tion, the necessary preliminaries must receive careful attention. 
In order to secure a healthy action of the skin Dr. Emmett advises 
a steam or hot-water bath to be given several nights in succession 
before the operation. After the body has been well washed with 
soap, and dried, he advises that it be thoroughly rubbed by the 
hand smeared with vaseline. On the morning of the day set for 
the operation the patient should receive a copious enema of hot 
soap-suds, being at the time placed on her knees and elbows, as 
this position favors the more ready removal of flatus and hardened 
feces. The diet for several days before the operation should be 
nourishing, but simple, and easily digested. Dr. Peaslee recom- 
mends milk porridge chiefly, but it is probably better that the 
patient be allowed a little mutton or fowl. Breakfast should be 
eaten some three or four hours before the operation, and to avoid 
vomiting from the anaesthetic, should be very light, usually a piece 
of toast and a cup of tea or glass of milk, being all that it is best 
for the patient to take. 

The patient should be clad in a warm flannel undergarment, 
long woolen stockings, her ordinary night-dress being slit down 
the front, above which she may wear a loose woolen jacket. The 
catheter should be used, if necessary, half an hour prior to the 
operation, and the upper part of the pubes should be shaved if the 
hair approaches the line of incision. The operation should be 
performed about noon, and the room selected should be airy and 
well lighted, and, if possible, have a southerly or westerly exposure. 
If possible, the carpet and all unnecessary furniture should have 
been removed the previous day, and the room well scrubbed and 
the spray from several quarts of a five per cent, solution of car- 
bolic acid be used upon the floor and walls of the room, as well as 
upon the furniture. 

At the time of the operation the room should show a temper- 
ature of 80 ° F., but no higher. The operation may be performed 
upon a common strong dressing table, well supplied with quilts or 
blankets which are covered by an india-rubber cloth. The bed 
which is to receive the patient should be in an adjoining room, 
and should, if possible, be provided with a hair mattress, the tem- 
perature of the room being kept, at least until several hours after 
the operation, at 80 ° F., but it may be lowered to 75 ° F., if the 
condition of the patient warrants it. 

Before preceding with the details of the operation I will say 
a word in regard to the use of the carbolic-acid spray, or Listerism. 
While there can be no question as to the value of this method in 
ordinary surgical procedures, yet it is quite unfortunate that, 
owing to the fact that the peritoneum readily absorbs the carbolic 
lotion, and thus frequently gives rise to serious toxic conditions, 



OVARIOTOMY. 351 

it has been generally abandoned in intra-abdominal operations. 
But while this is true as regards the carbolic-acid spray, yet List- 
erism may be said to be employed in a more or less modified form 
by nearly all operators. The placing of the instruments in a tray 
of carbolized water, the washing of the hands in carbolized water, 
the previous sprinkling of the room with the same, are among the 
many antiseptic precautions usually adopted, and I think there is 
no doubt that all Listerian precautions should be observed except 
the spray. A perfect system of asepsis is absolutely required, and 
if this is faithfully carried out the spray can easily be dispensed 
with. Hart and Barbour remark that (1) " it is evident that ovario- 
tomists must find some method which, while locally purifying the 
air, will yet be innocuous to the wound surface." This I feel that 
we already have by using a spray of peroxide of hydrogen. This 
agent is entirely innocuous, and at the same time is one of the best 
of germicides. Pean has used it for this purpose with entire satis- 
faction, but I know of no other operator of distinction who has 
followed his example. Dr. Emmett advises the use of a spray of 
clear water in the room in order to keep it in a moist condition. 
"Were the peroxide of the hydrogen used instead of water, it would 
answer this purpose, and also that of a germicide at the same time, 
without causing an}' of the untoward symptoms either in patient 
or operator that so often arise from the use of carbolic acid. The 
only valid objection to the use of this agent in the form of a spray 
is that when exposed to the atmosphere it loses its excess of oxygen 
and therefore becomes inert so far as its germicidal qualities are 
concerned, and that, to accomplish this purpose, the spray must be 
directed into the abdominal cavity, which, however, could be 
done without annoyance or danger. 

It is the custom of most operators to notify the family a few 
days before the operation that they must have in readiness the 
following articles: one yard of rubber plaster; two rolls of cotton 
wool, made aseptic by being baked in an oven just before the 
operation; two and a half yards of white flannel, for two binders; 
a pint of whiskey, with a cup, spoon and sugar; a nail-brush, basin 
and soap; a pin-cushion with large pins; a solid table, upon which 
to operate; a small stand for the spray apparatus, in case one is to 
be used; a small table for basin and sponges; two new tin basins 
and one tin cup; a new bucket, and several bottles for hot water; 
a small tub and a common bucket; a rubber cloth one and one- 
quarter yards square, with an oval hole in the center six inches 
wide and eight inches long; one clean blanket for the patient's 
lower extremities; a small table for instruments; a plentiful supply 
of clean towels, sheets, blankets and pillows, and an unlimited 

1) Manual of Gynecology, p. 223. 



352 A TEXT-BOOK OF GYNECOLOGY. 

supply of hot water. In addition the surgeon will require: anaes- 
thetics; a 2 per cent, solution of carbolic acid for the instruments, 
and with which to wash the hands thoroughly; a spray -producer, 
if one is to be used; a,porcelain or tin tray for instruments; ten 
fine surgeon sponges of different sizes; two long and flat sponges; 
antiseptic gauzes, and the following instruments : — ordinary 
knives; probe-pointed curved bistoury; one grooved director; scis- 
sors, straight and curved; dissecting and dressing forceps; tena- 
cula; blunt hook; volsellum forceps; needle-holder; two dozen 
straight surgeon's needles; assorted needles of varying curves; 
two large needles for transfixing pedicle; aneurism needle; assorted 
carbolic silk; fine catgut for bleeding vessels; hypodermic syringe; 
two pairs Nelaton's cyst forceps; Well's trocar, with rubber tub- 
ing; clamp; Paquelin's cautery, or three cautery irons; drainage 
tubes; aspirator; wire ecraseur. 

Of course all of these articles are never used in any one ope- 
ration, but any one of them may be needed, and it is wise to have 
them in readiness. The number of articles in use during the 
operation, especially of sponges and artery forceps, should be 
carefully noted, and counted before the abdomen is closed, that 
none of them may be left within the abdominal cavity. It is im- 
portant that the sponges be all new and carefully bleached with 
dilute muriatic acid, washed free of any particles of sand, and well 
carbolized. Dr. Emmett advises that the silk ligatures should be 
thoroughly boiled and placed in melted wax, then stripped of the 
superfluous wax by the fingers, and both stretched and twisted 
tighter while still warm. He also advises that they be soaked in 
a solution of bichloride of mercury — 2 to 1000 — for at least half 
an hour before use. These precautions are not, however, usually 
adopted by those who use the carbolized ligatures. 

Four assistants are necessary. These and the surgeon should 
wash their hands, face and hair thoroughly with soap and carbol- 
ized water, and use the nailbrush with still stronger carbolized 
water. They should not have visited any cases of zymotic or con- 
tagious diseases on that morning, and their clothes should be 
scrupulously clean. Dr. Goodell advises, in order to ensure fur- 
ther protection, that each one should take off his coat, vest and 
neck-tie, if they are of material that cannot be washed. All by- 
standers, if any are allowed, should be made to conform to ail 
these rules as near as possible. It is quite unfortunate that these 
important precautions are so often disregarded. 

The following preliminary details are observed by Dr. 
Emmett (1): A warm blanket should be spread over the lower 
end of the table, with which to envelop the legs and feet of the 

1) Op. Cit., p. 718. 



OVARIOTOMY. 353 

patient as they hang over to rest upon a chair. Her night-gown 
and undershirt should be rolled up to a point at which they cannot 
become soiled. A small pillow should be pushed under the mid- 
dle of her back for support, and the other pillows so placed at an 
angle as to make her position comfortable. The operator will 
select the side of the patient on which he is to stand, according to 
the direction of the light, or as he may have a preference. His 
chief assistant will stand on the other side of the operating table 
opposite to him, ready to sponge when necessary. A third per- 
son may stand at the side of the chief assistant nearest the patient's 
head, for the purpose of keeping up steady pressure while the 
tumor is being emptied. This he does by applying his open hands 
flat on each side of the abdomen. Afterward he may be needed 
to assist the person giving ether, to look after the condition of the 
patient, and to give hypodermic injections of brandy, if they 
should be needed. 

The person administering the anaesthetic should be particu- 
larly skilled therein, and so familiar with the operation that he 
may not neglect the anaesthesia in his anxiety to witness it. The 
operator should on no account have his attention called from the 
work before him. The fourth assistant is to have charge of and 
to wash the sponges. 

As the patient passes under the influence of the ether, a folded 
napkin should be placed between her knees, the legs tied together 
and secured, if necessary, to the back of the chair, or, better, to 
the table. A large receptacle must be placed under the table for 
receiving the contents of the tumor, and alongside of it a small 
hand-bowl, to be used for the same purpose when more convenient. 
Xear by must be placed a supply of towels and a basin of warm 
water, in which the operator may dip his hands from time to time, 
and it should be the duty of some one person to change frequently, 
during the operation, the water which has been carbolized or had 
the bichloride added. 

Before beginning the operation it must be seen that in front 
of the fire, or heating apparatus, have been placed several blankets, 
a change of clothing for the patient in case she should need it, and 
a sufficient supply of hot water. The patient's bed must also be 
properly prepared. It should be narrow, that the patient may be 
readily reached; the mattress should be of hair, and hard, protect- 
ed by a rubber sheet and covered by a blanket and cotton sheet 
for the patient to lie upon. Along the center of the bed a num- 
ber of vessels of hot water, tightly corked, are to be placed, and 
covered up by the bed-clothing. 

The patient is now placed upon her back on the table, the lat- 
ter being so placed that her feet are toward the window. The 



354 A TEXT BOOK OF GYNECOLOGY. 

anaesthetic is then administered. Ether is the safest and is usually 
employed. The ACE mixture — One part alcohol, two parts chloro- 
form, and three parts ether, is more rapid in its action, and is by 
some surgeons considered equally safe. "To prevent vomiting 
and to put the patient to sleep without a waste of ether or loss of 
time, Dr. Ludlam gives one ounce of whiskey in some water &vq 
minutes before the anaesthetic is given. I believe this to be an 
excellent practice, and, what is still better, is, to commence adminis- 
tering whiskey some three or four hours before the operation, giving 
the patient enough during that time to put her completely under 
its influence. If, then, she should show signs of consciousness 
during the operation, a very few whiffs of chloroform or ether 
are all that is required. Dr. Obetz, of the University of Michi- 
gan, employs this method, and considers that it has many advan- 
tages over any other in operations that may prove tedious.* 

As soon as anaesthesia is complete, the rubber cloth with an 
oval opening is placed in its proper position, the edges being re- 
tained by adhesive plaster, the patient is tied as before mentioned, 
and the operator and his assistants take their respective positions. 
The abdominal incision should be made in the median line below 
the navel, and should be about three inches in length, its lower 
limit being about an inch above the symphysis. The tissues divi- 
ded in their order are the skin, fat, linea alba, transversalis fascia, 
extra-peritoneal fat, each of which are successively laid open upon 
a grooved director, and finally the peritoneum, the recognition of 
which is all important. It has a dull, dark-blue appearance, while 
the wall of the tumor is of a whitish blue, or pearl-like color. 
The peritoneum should be carefully opened by catching it up with 
a pair of forceps, snipping a small opening for the introduction of 
the grooved director, and then dividing it with the scalpel or scis- 
sors. Before the opening of the peritoneal cavity, however, the 
operator should be careful that all bleeding has been stopped, 
either by torsion or the application of artery forceps, which may 
remain, or the vessels may be ligated with catgut. 

The incision being now completed, the next point should be 
the completion of the diagnosis. The diagnosis, moreover, should 
now include not only the fact that we have an ovarian tumor to 
deal with, but a considerable knowledge of its attachments and 
adhesions. For this purpose a clean metallic bougie or sound may 
be passed over the surface of the tumor in all directions where it 
will go without obstacle, but the forefinger is the best of all 



*) After the above was written I read the remarks upon this subject made by Dr. Link at 
the recent International Medical Congress. He said that he had used "alcohol as an anaesthetic 
in over a hundred cases, and never had a fatal result, while the anaesthesia was complete. 
The whiskey to be given in two ounce doses every two to five minutes, until a pint to one and 
a half pints have been taken, and the patient has'become stupefied. Then about two drachms 
of chloroform are placed in the cone, and a few respirations put him to sleep." 



OVARIOTOMY. 355 

sounds. With this the operator can generally reach down in front 
to the lower end of the globular mass, and can even ascertain 
something of its attachments or pedicle, and feel the uterus and 
trace its fundus. Any slight adhesions to the abdominal wall or 
omentum, which are felt as thread-like bands, are easily torn off 
the tumor at this time, two, three or more fingers being used if 
necessary, but those which are firm and unyielding should be left 
until the cyst is partially drawn out from the abdomen. 

The diagnosis being satisfactory, and it having been decided 
to proceed with the operation, the opening is carefully enlarged to 
from five to six inches or more, as necessity requires, a semi-solid 
tumor requiring a larger opening than one which is mere fluid in 
its nature. Sometimes it will already have been found that the 
sac is firmly adherent to the abdominal wall, and unless care is 
exercised this may not have been discovered until after part of the 
peritoneum has been stripped off under the impression that it is 
the sac wall, and much trouble will result therefrom, especially in 
the way of hemorrhage. 

The next step is the evacuation of the cyst contents. This is 
accomplished by the use of a trocar and canula, Wells' trocar 




Fig. 186.— Wells' Ovarian Trocar. 

being most often used. This instrument, ' with its point projected, 
is plunged into the sac at a point free from blood-vessels, the 
shield being immediately pushed out to guard the point, and the 
fluid passes through the attached tubing to a pail placed below the 
table. Meanwhile an assistant keeps up steady pressure on the 
abdominal walls, in order to prevent the intestines from passing 
out. Should there prove to be more than one cyst they must each 
be treated in a similar manner. The cyst having been emptied, if 
there are no adhesions to prevent, it is drawn out from the abdo- 
men by means of a pair of Nelaton's forceps, the assistant still 
keeping up pressure upon the abdominal walls. This much having 
been accomplished, the operator now has the cyst outside the 
abdomen, while the pedicle is at the incision. 

It may happen, however, that the adhesions are so extensive 
that the sac cannot be drawn out. If this is the case, Dr. Emmett 
advises to tap the patient on her side, as first recommended by 



356 



A TEXT-BOOK OF GYNECOLOGY. 



Wells. As this question of the treatment of extensive and firm 
adhesions is of great importance, I prefer to quote at length from 
Dr. Emmett, than whom there can be no more reliable authority. 
He says (1): u The patient can be turned well over on the side, and 




& 



I 



be thus held by the assistants, while the operator gradually draws 
out the sac by means of any strong forceps or volsella constructed 
for the purpose. A linen cloth must be placed under the tumor 
and over the lower edge of the wound, to receive any cystic fluid, 
which might by accident escape alongside of the cannula, other- 
wise it may enter the abdominal cavity. As the abdominal walls 
become more relaxed the upper edge of the incision should also be 



1) Op. Cit., p. 



OVARIOTOMY. 357 

covered by a linen cloth to protect the parts, and to keep the hand 
of the assistant from coming in direct contact with the intestines, 
which are liable to protrude. 

' ' The most frequent seat of the adhesions is the abdominal 
walls and next the omentum covering the anterior surface of the 
cyst. They may be found in both places. 

' ' Great care and skill are required to separate the adhesions 
between the tumor and the abdominal walls. This separation must 
be made, as has been stated, by tearing off the adhesions from the 
surface of the tumor, and never from the abdominal wall, as this 
would leave the muscular tissue exposed without any peritoneal 
covering, which would delay and complicate the progress of the 
operation. But when the adhesions are separated from the sur- 
face of the tumor, it rarely happens that any large blood-vessels 
are lacerated, and what capillaries are torn will promptly close up. 

"If the omentum, as indicated by its appearance, is found to 
be adherent to the tumor at the abdominal opening, more care 
must be exercised in making traction, through fear of tearing the 




Fig. 189.— Wells' Ovarian Clamp. 

connection of the omentum with the intestine beyond. It is not 
necessary to delay for the purpose of attempting to separate the 
omentum from the surface of the tumor, but just beyond the ad- 
hesion two ligatures may be placed an inch apart, around the mass, 
which may then be divided between the ligatures with a pair of 
scissors. This will prevent any bleeding from the tumor, and the 
ligature from the end attached to the omentum should be placed 
in charge of an assistant while the stump is temporarily returned 
to the abdominal cavity. 

c ' Adhesions are sometimes formed with the lower surface of 
the liver, and to the stomach and small intestines. If these are 
carelessly broken up, the substance of the viscera may be torn, 
and fatal results follow. When slight they may be separated from 
the surface of the tumor; but the safest plan is to cut around the 



358 



A TEXT-BOOK OF GYNECOLOGY. 



adhesions so as to leave the adherent part of the cyst-wall intact, 
and then carefully strip off the portion of lining membrane. If a 
vessel is divided it must be secured with a fine silk ligature." 

When the tumor has been thus sufficiently reduced in size to 
be drawn out of the abdominal cavity, it should be wrapped in a 
towel to preserve its warmth and circulation until the pedicle can 




Fig. 190. — Thomas' Ovarian Clamp. 



be divided. The patient is then to be turned on her back, the 
abdominal incision to be held open, so that the small intestines and 
the parts of the pedicle may be covered by pieces of' linen cloth 
wrung out of warm water, to which carbolic acid has been added. 
This will protect the intestines from cold and from the continued 




Fig. 191. — Dawson's Ovarian Clamp. 

action of the spray, and will absorb any blood which may ooze from 
the walls, or from the pedicle after it has been divided. 

The same method is equally desirable when there are no 
adhesions, but it is seldom practiced. 

After the sac has been withdrawn, the next step is to secure 
the pedicle, which is one of the most important features of the 
operation. This may be done by the clamp, by the cautery, or 
by the ligature. The first is called the extra-peritoneal method; 
the others the intra-peritoneal. Until within a few years the clamp 



OVARIOTOMY. 



359 



was mostly used, but it is now almost abandoned, the ligature and 
dropping back of the pedicle being the favorite and probably the 
best method. 

Actual cautery may be performed with cautery irons, or 
Paquelin's instrument, which is considered most desirable. By 
this method no foreign body is left in the abdominal cavity, except 
the charred portion of the pedicle. There are very many ova- 
riotomists, Keith among the number, who adopt this treat- 
ment. For the process a cautery clamp is required, with which 
the pedicle is seized, after which the cyst is cut off about 
an inch above the clamp. The cautery irons, or the Paquelin, are 
then passed firmly over the surface until the pedicle is seared flush 




Fig. 192. — Paquelin's Thermo-Cautery. 

with the clamp. The peritoneal toilet is then finished, after 
which the clamp is carefully unscrewed and removed, the pedicle 
being firmly held meanwhile with a pair of forceps, and if all is 
right it is dropped into the abdomen. 

The ligature, however, is, as I have already remarked, the 
most popular and probably the best method of treatment. It 
should be made of thin carbolized silk. Some use silver or catgut, 
but the silver being inelastic cannot bind a shrinking pedicle, and 
the catgut is liable to slip or untie. The method usually employed 
is that given by Hart and Barbour (1): " A double silk ligature is 
threaded on a blunt needle. The pedicle is transfixed with this, 
and the ligature cut. Thus we have two ligatures through the 



1) Op. Cit.. p. 220. 



360 A TEXT-BOOK OF GYNECOLOGY. 

pedicle; one is passed round the one half of the pedicle, the other 
round the other half. They may be made to interlace first so as 
to make a figure-of-eight. Each is tied firmly in a reef knot. The 
pedicle is then seized with Pean's forceps, one on each side below 
the ligature; the cyst is clipped off about half an inch on the cyst 
side of the ligature; as the pedicle is still held up by the forceps 
it can be carefully examined to see if any bleeding occurs. It 
should be noted whether the ligature splits the pedicle vertically, 
so as to cause bleeding, if so, the ends of the thread can be made 
to surround the whole pedicle below this. If there is no bleeding 
the ligature is cut short and the pedicle dropped into the pelvis. 
The raw end of the pedicle may be stitched with catgut to the 
broad ligament, so as to prevent its adhering to and constricting 
the intestine. 

"When the pedicle is thick and fleshy it may require to be 
tied in three portions, as follows : Pass a double thread so that 
its shorter half will embrace only one-third of the pedicle ; with- 
draw the needle, but keep it still running on the thread and use it 
to carry the longer half of the thread through a second point, so 
as to embrace the middle third of the pedicle ; one portion of the 
longer half thus forms a loop round the middle third, while the 
other portion embraces the other third of the pedicle. 1 ' A careful 
examination of the other ovary is now made, and, if it is found to 
be diseased, it is ligatured and removed. 

Next comes the peritoneal toilet, which also includes a careful 
search for any bleeding points that may have been left by the torn 
adhesions, and under no circumstances should the abdomen be 
closed until every vestige of hemorrhage or of its products has 
been removed. Dr. Ludlam, in order to more thoroughly secure 
the removal of blood and serum, is ' ' in the habit of inverting the 
posterior cul-de-sac with the finger." The cavity having been 
carefully mopped and thoroughly dried, a flat sponge, the full 
length of the incision, is laid over the intestinal contents and 
allowed to remain until the external sutures are placed, but not 
tightened ; it is then carefully withdrawn. 

After the sponges and instruments are all counted the wound 
is closed. For this purpose silver wire sutures are usually em- 
ployed. Each needle is passed from within outward a quarter of 
an inch away from the peritoneal edge of the wound, and is made 
to emerge at the same distance from its cutaneous edge. Most 
surgeons pinch the peritoneum and skin together, so that the needle 
passes through them alone without including the recti muscles, 
which, if included, may give rise to abscesses in the track of the 
sutures. Dr. Goodell, however, considers that the observance of 
this rule may cause hernia in the track of the wound, so he includes 



OVARIOTOMY. 361 

these muscles in the suture whenever they are exposed to view. 
Each suture should be about eight inches long, and they should be 
placed about half an inch apart, beginning at the upper end of the 
wound. All the sutures are passed before any of them are twisted, 
and the ends of the sutures on each side are raised together, which 
brings the edges of the wound together, and at the same time 
chases the air out of the abdominal cavity. These being held by 
an assistant, the surgeon rapidly tightens and twists each ligature. 
After all have been twisted, the free ends of each ligature are cut 
off about two inches from the knot, with a pair of scissors. 
Should there be any gaping points, superficial sutures are passed 
through the skin, bringing the edges of the wound into coaptation, 
but neither the deep nor superficial sutures should be drawn so 
ti^ht as to cause inversion of the ed^es of the wound. 

In ordinary cases no drainage is required, but when there have 
been extensive adhesions a glass drainage tube should be passed in 
at the lower angle of the wound and down into Douglas' cul-de- 
sac, before the lower sutures are twisted. The mouth of the tube 
should be closed with a sponge or absorbent cotton, which will take 
up the discharges ; or, in severe septic cases, the fluid collected in 
the cavity may be pumped out through the tube with a syringe or 
aspirator; the cavity may, if deemed necessary, be washed out 
with antiseptic fluids. The tube may be arranged so that it will 
open upon the surface of the dressings, or it may be covered by 
the flannel bandage. The tube may usually be removed in about 
forty-eight hours, though it may be left longer if required. After 
its removal the opening in the wound is closed by twisting a wire 
suture which has been left loose for that purpose. 

There are many methods for the dressing of the wound, but 
one of the most simple and effective is that practiced by Dr. Lud- 
lam and most other homeopathic surgeons. It consists in applying 
strips of adhesive plaster across the abdomen, and then covering 
the wound with a compress of old linen that has been saturated 
Avith a ' ; mixture of equal parts of the tincture of calendula, gly- 
cerine, and warm water." Some do not include the glycerine, but 
Dr. Ludlam thinks that ' ' the glycerine keeps the parts moist and 
supple, excludes the air, and is an excellent antiseptic." Over this 
a flannel bandage is pinned. Spencer TTells uses for this purpose 
gauze saturated with a mixture of thymol and spermaceti, laid 
over the united wound. Then eight or ten folds are put over the 
first, and the whole supported with strips of adhesive plaster, over 
which is tightly fastened the flannel binder. In ordinary cases the 
dressings may be left untouched for eight or nine days. But 
should there be a rise in temperature it may be necessary to ex- 
amine the wound, and of course if there is much discharge the 



362 A TEXT-BOOK OF GYNECOLOGY. 

dressings will need frequent changing. In such cases Dr. Ludlam 
advises the dressings to be changed and the wound cleansed every 
alternate day. The operation being now completed, the patient is 
carefully placed in the bed which has been made warm and ready 
to receive her. 

After-Treatment. — To the general practitioner the after- 
treatment is of greater importance than the operation itself, as in 
a majority of cases, the surgeon having performed his task, leaves 
the responsibility of the subsequent care of the patient to the 
attending physician, and it is upon his judgment and skill in a 
great measure that the safety of the patient depends. 

The first danger to contend with may be a collapse from 
nervous shock. There is always more. or less shock following the 
operation, but this usually disappears after the patient is covered 
with warm blankets and hot bottles have been applied to the feet, 
limbs and body. If, however, there is a tendency to collapse, and 
the patient shows no signs of reaction, she should be given small 
doses of brandy or whiskey, or, what may be found still better, the 
subcutaneous in j ection of twenty minims of sulphuric ether. If there 
is vomiting from the anaesthetic, the patient should be encouraged 
to take deep inspirations, as this will help rid the blood of the 
anaesthetic. Arsenicum may also prove of benefit, but as a rule 
no remedies are required. If flatus becomes annoying, it may be 
usually got rid of by turning the patient on her side and inserting 
a flexible catheter high up in the rectum. The abdomen may, 
however, become so bloated that it will be necessary to loosen the 
bandages. The diet should for at least forty-eight hours be extremely 
light, a few teaspoonfuls of iced milk, or of peptonized beef, or a 
few sips of hot tea, are all that should be allowed, in order that 
vomiting may not be induced, and the collection of flatus be pre- 
vented. Hart and Barbour recommend that hot water "be given 
ad libitum, as it helps the flatus. " After the second day the food 
may be cautiously, increased, first allowing larger quantities of 
milk and peptonized beef, or beef tea. At the end of a week the 
bowels should be opened by an enema, but a cathartic should 
never be employed. The urine should be drawn off about every 
three hours at first, but after the first day every six hours will 
answer. 

The first serious complication may be secondary hemorrhage, 
which, if from the pedicle or the adhesions, may make it necessary 
to open the wound and ligate the bleeding vessels. 

The next complication, which is to be anticipated and guarded 
against, if possible, is that of high temperature. The thermometer 
should be used every morning and night, and should it mark a 
temperature of 101 ° F. or over, the patient should be placed upon 



OVARIOTOMY. 363 

the indicated remedy at once — probably Aconite, or, possibly, 
Arsenicum, Belladonna, or Veratrum viride, and at the same time 
an ice cap should be applied to the patient's head. The ice cap is 
allowed to remain so long as it feels comfortable and does not 
make the patient chilly, and at the same time the face and extrem- 
ities should be frequently sponged with tepid water. It is usually 
considered, and with truth, that if the temperature can be reduced, 
there is less danger of septicaemia, but reducing the temperature 
does not remove the blood poison, it is simply an evidence that the 
blood and serum which have oozed into the abdomen have been 
absorbed without septic poisoning having occurred. But as Dr. 
Emmett well says, (1) "The reduction of temperature is all very 
well, as far as it goes, but the patient will die in spite of it, unless 
the decomposing bloody serum is removed from the peritoneal 
cavity." 

In order to accomplish this, when drainage has been employed 
the peritoneal cavity may be washed out with a very weak solution 
of carbolic acid, by means of a syringe or aspirator. It may become 
necessary to reopen the abdomen in order to do this. Opium and 
other narcotics have no place either here or elsewhere in the treat- 
ment of these cases, and should never be employed. 

The chief indications for the remedies most often called for 
in septicaemia are as follows: — 

Arnica. — Stupor; indifference; unconsciousness; when spoken 
to answers correctly, but unconsciousness and delirium return at 
once; tympanitic distension of the abdomen; involuntary stools; 
petechias; ecchymosis. 

Arsenicum. — Great restlessness and anxiety; face sunken and 
pale, sometimes covered with a cold sweat; tongue dry and brown; 
nausea; burning pains in abdomen, which is much distended; 
involuntary, dark-colored, offensive stools; pulse quick, weak and 
irregular; great prostration. 

Baptisia. — Great confusion of mind; face dark red, with a 
besotted expression; sordes on the teeth and lips; tongue dry, 
and brown down the center; abdomen distended; tightness in the 
chest; all discharges and exhalations very fetid. 

Also consult Carbolic acid, Carbo veg. , Chininum sulph. , Crot- 
alus, Eucalyptus, Hepar sulph., Lachesis, Mercurius, Muriatic 
acid, Phosphorus, Rhus tox. 



1) Op. Cit., p. 737. 



CHAPTER XLVI. 



PELVIC PERITONITIS. 



Synonyms. — Pel vi-peritonitis ; perimetritis ; pelveo-peritonitis. 

Definition. — An inflammation of the peritoneum, which, is 
limited to that portion covering the female pelvic viscera. 

In considering the nature of pelvic inflammations we are at once 
embarrassed by the evident confusion that exists among all authors 
as to the relation which exists between peritonitis and cellulitis. 
Some regard them as positively distinct affections ; others consider 
that the one cannot and does not exist without the other, and there- 
fore regard them as practically one affection. Thomas, having 
carefully studied this point, has arrived at the following conclu- 
sions (1), which agree with those of other recent authors : — 

1 . " Peri-uterine cellulitis is rare in the non-pregnant woman, 
while pelvic peritonitis is exceedingly common. 

2. " A very large proportion of the cases now regarded as 
instances of cellulitis are really those of pelvic peritonitis. 

3. "The two affections are entirely distinct from each other, 
and should not be confounded simply because they often compli- 
cate each other. They may be compared to serous and parenchy- 
matous inflammation of the lungs — pleurisy and pneumonia. 
Like them, they are separate and distinct; like them, they affect 
different kinds of structure, and, like them, they generally compli- 
cate each other. 

4. "They may usually be differentiated from each other, and 
a neglect of the effort at such thorough diagnosis is as reprehensi- 
ble as a similar want of care in determining between pericarditis 
and endocarditis." 

Schrceder (2) is of the opinion that cellulitis is a connect- 
ive-tissue phlegmon, which is due to an infection with septic 
material ; hence, that it is common in the puerperal state, but at 
other times is tolerably rare, and that perimetritis is a partial peri- 
tonitis, which may be, and frequently is, induced by the most 
diverse causes. 

Pathology. — The disease maybe described, like other peri- 
toneal inflammations, as having three stages. During the stage of 
congestion there is simply engorgement and turgescence of the 

1) Diseases of Women, p. 466. 

2) Ziemssen, Vol. X, p. 445. 



PEL VIC PERITONITIS. 365 

vessels, producing redness, dryness and pain. The second stage is 
that of plastic exudation, in which plastic lymph collects on the 
surface of the peritoneum, and serous or sero-purulent fluid is 
poured into its most dependent parts. After this has taken place 
the sensation to the touch is likened by Thomas (1) to that as if a 
fluid mixture of plaster-of-paris had been poured in, around, among 
and over the organs of reproduction as they lie ' ' in an atmosphere 
of cellular tissue," and afterward becoming solid. "The uterus, 
which is generally much displaced, is immovable, and all its ap- 
pendages appear fixed by some solid surrounding element." 

In the third stage the fluid, if serous, is absorbed ; if pur- 
ulent, discharged, and the exuded lymph undergoes organization 
and subsequent contraction. This binds the uterus, its appendages, 
and some of the intestines together in a mass, which yields all the 
physical signs of a tumor. 

Etiology. — Pelvic peritonitis may be caused by — 

(1) Pelvic Cellulitis. — The intimate association of these 
diseases has already been mentioned. The pelvic peritoneum and 
cellular tissue are adjacent and intimately connected with one 
another in their vascular, nervous, and, especially, in their lym- 
phatic supply, so that we can readily understand how an inflamma- 
tion affecting the one may easily involve the other. 

(2) Endometritis, ovaritis or salpingitis may also cause 
pelvic peritonitis by extension, and the latter by emptying its accu- 
mulated pus into the peritoneal cavity. 

(3) Parturition and abortion. — Cellulitis is the form of pel- 
vic inflammation usually following these states, a septic condition 
being present, but pelvic peritonitis may occur in the same manner, 
and may also be caused by injury during labor. 

(4) Gonorrhea. — This is a common cause of pelvic peritoni- 
tis. The inflammation results from actual spread of the gonor- 
rheal virus, or it may be sympathetic, like orchitis in the male. In 
the former case the purulent infection probably passes along the 
Fallopian tubes and out at the fimbriated end, setting up a severe 
peritonitis. According to Noeggerrath, (2) a very common cause 
of pelvic peritonitis is what he is pleased to call a latent gonor- 
rhea in the male. He believes that the disease, once contracted, 
is probably never entirely eradicated, but that it always exists in 
a latent form, and that it is capable of producing a specific inflam- 
mation of the pelvic peritoneum years after an apparent cure had 
been effected. 

(5) Escape of fluids into the peritoneum is a frequent cause. 
This may occur by the rupture of a cyst or an abscess, or by an 



1) Op. Cit., p. 471. 

2) "Latent Gonorrhea, etc." Transactions American Gynecological Society, Vol .1, p. 268. 



366 A TEXT-BOOK OF GYNECOLOGY. 

intra-peritoneal hemorrhage, or from regurgitation of menstrual 
fluid through a too patulous Fallopian tube. It not infrequently 
occurs from intrauterine injections. I once saw a case where 
death resulted from a peritonitis which was set up by an intra- 
uterine injection of the chloride of chromium. 

(6) Menstruation. — It may easily be understood how the 
congestion of menstruation may sometimes cause peritonitis. 

(7) Traumatic Influences. — Pelvic peritonitis is occasionally, 
though rarely, caused by blows upon the abdomen or other acci- 
dental wounds, the most frequent traumatic cause being in connec- 
tion with surgical operations, or from instrumental manipulations 
in the use of the sound, or the introduction of intra-uterine pes- 
saries, sponge tents and the like. Excessive coitus has been named 
as a traumatic cause, but it is probable that in such cases other 
causes, as gonorrheal infection, for instance, have much to do with 
producing the disease. A most prolific cause is induced abortion. 
It might be said that there is scarcely any affection of the internal 
genital organs which does not to some extent involve the pelvic 
peritoneum, and secondary pelvic peritonitis is, therefore, a very 
common affection. 

(8) Tuberculous or cancerous disease of the pelvic organs is 
almost always complicated by more or less pelvic peritonitis. 

Symptoms. — These may belong either to the acute or chronic 
variety, and subjectively they differ but little from the symptoms 
of other acute or chronic forms of pelvic inflammation. In the 
acute form we find full, rapid, bounding pulse, increased temper- 
ature, rigors, and severe shooting pains. 

Physical examination reveals great tenderness of the lower 
part of the abdomen, and the abdominal muscles, apart from the 
patient's volition, resist pressure. She lies usually upon her back 
with both legs drawn up. The vagina feels hot and tender to the 
touch, and pulsating vessels may be felt in the fornices. After 
exudation is present, we may, according to Hart and Barbour, (1) 
"feel one or the other of the following conditions: — 

1. " A flat, hard, non-bulging condition of the fornices round 
the cervix, which is not displaced to one or other side, but is im- 
mobile. The usual simile, and a very good one, is that it feels as 
if plaster-of-paris had been poured into the pelvis. 

2. u An indistinct fullness high up in the pelvis. This is 
from free serous exudation. 

3. " A bulging tumor behind the uterus, displacing it to the 
front; or a tense fluid laterally, apparently in the site of the broad 
ligament. The former is due to encysted serous effusion in the 
pouch of Douglas, the latter to encysted serous fluid behind the 

1) Manual of Gynecology, p. 154. 



PEL VIC PERITONITIS. 367 

broad ligament, displacing it forward. As a general rule, these 
effusions are high in the pelvis, and symmetrical. Sometimes the 
bulging retro-uterine tumor feels nodulated after a time; this is 
from extension of the inflammatory condition into the subjacent 
connective tissue. 1 ' 

In chronic pelvic peritonitis the subjective symptoms are more 
obscure, being chiefly backache and sideache, and pain and dis- 
comfort in the region of the bladder. In addition there is leucor- 
rhea, disordered menstruation and sterility. Pain on vaginal 
examination or coitus is a marked symptom. The pain of chronic 
pelvic peritonitis is attended with but a very slight increase in 
temperature and acceleration of the pulse, being often so slight as 
not to be noticed. Frequently there is nausea and vomiting, and 
sometimes frequent and painful urination. 

As a rule, physical examination reveals a very similar condi- 
tion to that found in the acute form. There is thickening in the 
fornices, fixation and induration behind the uterus, the latter being 
usually markedly anteverted, though it may be retro verted and 
bound down by adhesions, in which the appendages are also 
included, being, as it were, glued together in the post-uterine space. 

The acute variety in its severest form, especially if of septic 
origin, may end fatally in a few hours, or may gradually pass, 
with frequent sub-acute exacerbations, into the chronic form. The 
latter, therefore, may occur as a sequel to the acute form, or may 
slowly develop primarily, and is almost indefinite in its duration, 
owing to the constant tendency to relapse. 

Diagnosis. — The diagnosis of acute pelvic peritonitis is com- 
paratively easy, as the tenderness on pressure, which is either 
diffused over the lower portion of the abdomen or confined to one 
spot, constitutes a sure sign of inflammation of the peritoneum. Yet 
the condition may be mistaken for either pelvic cellulitis, acute me- 
tritis, ovaritis or salpingitis, and also for recent pelvic hematocele. 

Acute ovarian or Fallopian inflammation can be distinguished 
from peritonitis only by the very distinct lateral localization of 
the pain and tenderness in the former condition. The occurrence 
of exudation in peritonitis also serves as a distinguishing feature, 
by revealing the wide extent of surface involved. 

Acute corporeal metritis is a rare affection. "If it forms a 
part of a general septic poisoning, some peritonitis will invariably 
accompany it; if it is traumatic, the history of the injury and the 
clearly definable uterine site of the pain and tenderness, as ascer- 
tained bi-manually, will guide us to the right diagnosis. 

' ' The differentiation of pelvic peritonitis from pelvic cellulitis 
in this early stage, is often impossible; but the following symptoms 
or signs will afford a strong clue : — 



368 A TEXT-BOOK OF GYNECOLOGY. 

1. "The formation of a distinctly resisting swelling in the 
pelvis, at a very early period, is in favor of cellulitis, especially if 
the tumor is not behind the uterus. 

2. u The pain on pressure in peritonitis is chiefly above the 
pelvic brim, and diffused, while in cellulitis it is chiefly within the 
pelvis, and in some one direction, more frequently in that of one 
iliac fossa. 

3. u The symptoms of nausea, vomiting, small wiry pulse, 
and tympanitis are very common in peritonitis, while in cellulitis 
they are usually absent " (1). 

Recent hematocele never shows inflammatory symptoms at 
first. There is acute and severe pain, but the rise in temperature 
and the excessive tenderness on pressure are absent. Some con- 
nection with the menstrual period, or with suppressed or over- 
profuse menstruation, is also generally found in hematocele. In 
fact, although it is in practice too often mistaken for peritonitis, 
this should never occur if the case is seen within a few hours. 

In chronic pelvic peritonitis the diagnosis depends almost 
entirely upon the physical signs. When the exudation is behind 
the uterus, and especially if it has bound the organ in a retroverted 
position, or incarcerated a foreign body, it is almost absolutely 
certain that agglutination is due to peritoneal exudation. This 
exudation is, as a rule, not so extensive as that which occurs in 
pelvic cellulitis, and if a tumor is present — which is uncommon — 
its location is different. When a tumor is present, as the result of 
pelvic inflammation, I think that it may be safely ascribed to 
connective-tissue inflammation rather than to peritoneal. On the 
other hand, when there is simply agglutination, and where the 
effusion seems thin and spread out, the organs and ligaments rigid 
and thickened, instead of a somewhat circumscribed tumor, the dis- 
ease may be ascribed to peritonitis rather than cellulitis (2). 

A retroverted or retroflexed uterus presents a freely movable 
tumor in the posterior cul-de-sac, and the sound reveals the back- 
ward course of the uterine canal. Bi-manual examination also 
reveals the absence of the fundus in its normal location. Sometimes 
a retroflexed uterus becomes secondarily, involved in pelvic exuda- 
tion, and fixed in its abnormal site, while the globular fundus is 
merged in more or less of lateral hardness; but even then, careful 
bi-manual examination, or probing of the uterine cavity, will place 
the uterine position beyond doubt, while the fixation and extended 
outline of the mass will often be made clear by the history of the 
intercurrent inflammatory symptoms. 

Fecal impaction may be mistaken for peritonitis, but the 



1) Thorburn, Diseases of Women, American Edition, p. 488. 

2) Baer, Pepper's System of Medicine, p. 231. 



PEL VIC PERITONITIS. 369 

position of the fecal mass, the absence of a history of inflamma- 
tion, and the independence and mobility of the uterus, will decide, 
or, at least, lead to a rectal examination. 

Fibroid tumors sometimes require differentiation from pelvic 
peritonitis. They are usually more or less spherical in form, and 
are firmly attached to the uterus, but, unless very large or im- 
pacted, they do not fix the uterus in place. The absence of a 
history of inflammation, the direction and depth of the uterine 
canal, and the more frequent presence of hemorrhage with 
fibroids, usually render the diagnosis comparatively easy. The 
presence of a carcinomatous mass in the pelvic cavity closely 
simulates the solid exudation of peritonitis, but the rapid growth, 
often without inflammatory symptoms, the cachexia and the ten- 
dency to oedema and ascites will usually remove all doubts as to 
the cancerous nature of the growth. 

Prognosis. — The prognosis as to life is usually favorable. If 
the inflammation becomes general, and is septic or gonorrheal 
in its origin, then the prognosis is very grave. 

Sterility often results from the permanent displacement of 
the uterus and its appendages. Abscesses are liable to form, and 
should these discharge into other organs, death may result. At 
the best, and where the symptoms do not become serious, there 
are such frequent recurrences, and the patient is so distressed from 
the uterine displacement produced by the adhesions, that life is 
made miserable, and only becomes in a degree comfortable after 
the menopause. 

Treatment. — This is practically the same, either from a 
medical or surgical standpoint, as the treatment of pelvic cellulitis, 
to which the reader is referred. 



CHAPTER XLVIL 



PELVIC CELLULITIS. 



Synonyms. — Parametritis, Peri-uterine cellulitis, Paracolpitis, 
Pelvic phlegmon. 

Definition. — An inflammation of the cellular connective tis- 
sue of the pelvis. 

It is claimed by Emmett (1) that "Pelvic cellulitis is by far 
the most important disease with which woman is afflicted," and 
that physicians fail to recognize it when circumscribed, " or do 
not appreciate its importance if by accident it is detected." "A 
great advance in the treatment of the diseases of women will be 
made whenever practitioners become so impressed with the signi- 
ficance of cellulitis as to apprehend its existence in every case. The 
successful operator in this branch of surgery will always be on the 
lookout for the existence of cellulitis, and take measures to guard 
against its occurrence." 

Pathology. — This disease not only affects the connective tis- 
sue which surrounds the vaginal vault and cervix, but it is also 
found in the utero sacral and broad ligaments, for within the peri- 
toneal folds of these ligaments there exists considerable cellular 
tissue. Under the inflammatory influences the connective tissue be- 
comes sodden or gelatinous, and is abundantly infiltrated with small 
cells. The disease may extend from the broad ligaments to the bones 
of the pelvis, along the round ligaments, behind the peritoneum, 
toward the kidneys, in short, in all the directions taken by puer- 
peral parametritis. We thus find this yellowish gelatinous infiltrate 
in the form of large or small tumors, small band-like cords, or 
delicate strands in all portions of the pelvic cavity where connective 
tissue exists (2). 

Cellulitis is generally found with greatest frequency, and in great- 
est severity, in those parts where cellular tissue most abounds, and 
where it is most liable to be injured. In cases of lacerated cervix 
the inflammation is almost always worse on the side on which the 
laceration is situated. The most common site of this process is at 
one side of the cervix uteri, from which it extends between the 
layers of the corresponding broad ligament. Hence a common 
diagnostic mark of cellulitis is its uni-lateral character. Both 



1) Op. Cit., p. 241. 

2) Winckel, Diseases of Women, p. 607. 

370 



PELVIC CELLULITIS. 37l 

sides may, however, be similarly and simultaneously affected. Or, 
the attack may originate in, or extend to, the tissue between the 
bladder and uterus, or behind, between the layers of the utero- 
sacral ligaments. The cicatrization of the utero-sacral ligaments 
which results from cellulitis produces increased anteflexion of the 
uterus, and thus becomes one of the most common causes of 
dysmenorrhea and sterility. 

Pelvic cellulitis may be divided into three stages. The first 
stage is that of congestion, giving the signs of pain, heat and 
swelling. The second stage is that of effusion, liquor sanguinis 
being poured into the tissues, causing hardness and tension. The 
third stage is that of suppuration, the whole course of the disease 
resembling that of an ordinary boil or abscess. 

Etiology. — The most important, and by far the most frequent, 
cause of pelvic cellulitis is parturition or abortion. It should be 
noted that the disease never occurs before puberty, and rarely 
before abortion or parturition have prepared the way, if, indeed, 
they have not acted as a direct exciting cause. This is explained 
by Dr. Baer, who says (1) "This is easily understood when w T e 
remember how compactly bound together are these ligamentous 
folds, and how small the cellular tissue spaces are before impregna- 
tion, when compared w T ith the condition of the parts after the func- 
tion of gestation has been performed. Even were no accident to 
occur to interfere with the perfect involution of the parts which 
enter into the process of the expulsion of the product of concep- 
tion, the tissues would probably always remain more vulnerable 
than before the gestation has occurred. But when the retrograde 
change which is necessary to perfect involution is retarded, a con- 
dition of relaxation and looseness of the parts results which increases 
manifold the liability to the affection. The blood-vessels and 
lymphatics remain large, and the connective-tissue cells are not 
only larger in size, but a cell proliferation is probably induced as 
a result of the increased amount of blood supply." 

In parturient women the great cause of pelvic cellulitis is septic 
matter absorbed by the lymphatics from the torn perineum, vagina 
or cervix. We may, for instance, have the cervix torn vertically 
at one side, and septic matter deposited there often speedily spreads 
by means of the lymphatic vessels. Then again, when the puer- 
peral state exists, it constitutes a predisposing cause, so that 
exposure to cold, fatigue, over-exertion, or direct injury will more 
easily induce pelvic inflammation. Abortion, whether accidental 
or induced, is a most prolific cause, because, according to Dr. Baer, 
it is so often followed by endometritis, which is frequently the 
starting point of pelvic cellulitis. 

1) Op. Cit., p. 209. 



372 A TEXT-BOOK OF GYNECOLOGY. 

Pelvic cellulitis may occur in non-puerperal cases, and when 
it does, the causes are similar to those already given under pelvic 
peritonitis, especially traumatic influences, ovaritis and exposure 
during menstruation. It is generally conceded that this disease is 
usually secondary to ovarian or uterine inflammation, whether 
puerperal or non-puerperal. 

Symptoms. — In recording the symptoms and course of pelvic 
cellulitis I shall follow Emmett, whose description is exceptionally 
graphic and complete. He says (1): — 

" An attack of cellulitis is generally ushered in by a chill of 
more or less severity, followed by fever. But, at times, the attack 
begins with pain and fever without any perceptible chill. Again, 
extensive cellulitis is occasionally detected by accident, after having 
become already well advanced without causing any particular dis- 
turbance. Fever and pain about the lower portion of the abdomen 
are, however, the usual symptoms. The pulse will become greatly 
increased in rapidity, and the thermometer, if placed in either the 
axilla or mouth, will indicate a marked elevation in temperature. 
As the temperature is usually at least one degree higher in the 
vagina, during an attack of local inflammation, it is better for the 
sake of greater accuracy to make the observation in the vagina. 
Unless the inflammation is very extensive, so as to involve the 
peritoneum, the symptoms are not always well marked, nor do 
they follow closely any rule. 

c ' If the attack is a severe one, there will be tenderness over 
the lower portion of the abdomen on either side, or over the whole 
surface. The abdomen will be found tympanitic and intolerant to 
pressure, while the patient will lie on her back with the knees well 
drawn up, and unable to extend them without increasing the pain. 
These symptoms are found accompanying an attack of hysteria, 
and this disturbance of the nervous system may even be an addi- 
tional complication with the cellulitis. But the elevation of tem- 
perature, as indicated by the thermometer, is an important diag- 
nostic sign, since there is no such change in hysteria alone. 

"Nausea may exist early in the disease, but vomiting, with 
the ejection of bile in large quantities, indicates a serious extent of 
the disease and general peritonitis. As the cellulitis becomes 
overshadowed by the extension of the peritonitis, the extent of 
the latter will be indicated by the expression of the patient's face, 
and by the tone of her voice. The features will become more 
pinched, and the voice will resemble closely the characteristic of 
the collapse of cholera. When the peritonitis has been unusually 
rapid in its progress, it seems to sear its way as the white heat of 
a cautery does, and to destroy sensation. I have seen such inflam- 

1) Op. Cit., p. 252. 



PELVIC CELLULITIS. 373 

niations begin as a cellulitis, extend to the peritoneum, and, becom- 
ing general, run their course in a few hours, without the slightest 
local suffering or even pain on pressure. From the shock and 
rapid depression to the life force, the temperature will fall even 
below the normal standard, while the pulse will rapidly increase, 
since the heart, from a loss of power, is now obliged to make a 
greater number of contractions. That the temperature should go 
down as the pulse increases in frequency is apparently an anomaly. 
The rule is, however, as applicable to all conditions of rapidly 
failing power. The explanation lies, at the beginning, in imperfect 
aeration of the blood in the lungs, from which the capillary circu- 
lation becomes diminished in proportion as the needed stimulus of 
oxygen is deficient. A depression in temperature on the surface 
would naturally follow, while the heart, although enfeebled, must 
increase its frequency of action to get rid of the accumulation of 
blood. Experience has taught that, in any acute disorder, it is 
the beginning of death when the temperature of the body falls to 
a point which is disproportionate to the extent of the disease, the 
pulse, at the same time, becoming rapidly and equally out of pro- 
portion. In such cases of peritonitis this is an infallible indication 
of the beginning of the end, notwithstanding the strength of the 
patient may yet seem fair, and other grave symptoms be absent. 

' ' In other cases, after a certain interval, there will be a re- 
mission of fever, but never a marked intermission until the com- 
mencement of resolution or convalescence. The temperature will 
continue above the normal point in the vagina, although the heat 
of the skin may seem natural, while, toward the close of the day, 
there will always be a perceptible rise in the general temperature. 
The symptoms will be all marked as a rule just in proportion to 
the extent of the peritoneum involved, and, in extreme cases, the 
pelvic condition may be marked entirely by the symptoms of the 
general peritonitis. In fact, without the aid of a digital examina- 
tion, the extent of the cellulitis would remain unknown. 

" The first shock of the disease is spent on the nervous system, 
whether the exciting cause be blood-poisoning, extension of the 
inflammation over a greater area, or the sudden occurrence of cel- 
lulitis itself. We can only recognize the result of the shock by 
the chill, during which the blood flows from the surface to the 
internal organs, producing intense pelvic congestion. Nature's 
first effort to relieve this will be by the escape of the watery por- 
tions of the blood through the coats of these vessels, and the tissues 
become infiltrated with serum. Then reaction comes on, by which 
the circulation is partially restored, and the fever correspondingly 
subsides. If the finger be now introduced into the vagina, no 
hardening of the tissues will be detected, but the sensation of a 



374 A TEXT-BOOK OF GYNECOLOGY. 

fullness and a boggy feeling will be appreciated, and there will be 
a marked elevation of temperature. 

" As the disease advances, so as to involve the peritoneum, 
the uterus becomes fixed in its position, and the roof of the pelvis 
tightened, as I have described. With this process, plastic lymph 
is thrown out, opposing sides of the peritoneum adhere and inclose 
the inflammatory products. Then the finger in the vagina will be 
able to detect roughened surfaces, as if hard masses of some foreign 
substance had become inclosed within the pelvic tissues. 

' ' When reaction occurs, if the circumstances are favorable, 
the oedema of the tissues rapidly disappears, and these hard masses 
melt away, as it were. The uterus soon becomes again movable, 
and the only product of the inflammation remaining afterward will 
be a band, formed from the shrinkage of the tissues which had been 
involved. Should the uterus or the intestines be bound down by 
adhesions, the former can be replaced by art, and the peristaltic 
action will in time liberate the latter. But the damage will be 
almost irreparable whenever the ovaries have been involved, or 
the broad ligaments, if of sufficient extent to include the Fallopian 
tubes. As the ovaries are stationary, they will remain buried in 
the lymph which has been thrown out, and, when this begins to 
undergo contraction, the supply of blood is diminished, so that 
they may become atrophied. Nerve-filaments are often involved 
in the mass and are compressed by the contraction, with the effect 
of causing ovarian neuralgia or reflex irritation elsewhere. To 
attacks of cellulitis, which may have produced but little disturbance 
at the time, can be traced the chief causes of sterility. 

4 ' The ovary may become covered in by a mass of lymph, as 
has been stated, so that the ova cannot escape from the Graafian 
follicles. The fimbriated extremity of the Fallopian tube may 
have been so bound down or displaced by adhesion as to be no 
longer able to grasp the ovary for the purpose of receiving the 
ovum as it escapes from the ovarian stroma. Or, some portion of 
the Fallopian tube may become obliterated by a band of adhesion. 
Moreover, these consequences are by no means dependent upon 
the apparent gravity of the attack. 

"After the subsidence of an attack, if nature alone, or aided 
by art, is unable to remove the product of the inflammation, 
symptoms of blood-poisoning present themselves in consequence 
of the absorption of septic material into the general circulation, 
as if it were nature's last effort to restore the integrity of the 
parts. The patient now suffers from rigors, followed by fever; 
and there is but a slight remission of these symptoms at any time 
in the day. The encysted lymph and serum break clown into pus, 
which, infiltrating the neighboring tissues, acts as a foreign sub- 



PELVIC CELLULITIS. 375 

stance, and sets up a fresh inflammation, causing their degenera- 
tion. A number of small accumulations of pus thus formed at 
length coalesce into one or more lar°'e abscesses. These accumu- 
lations of pus extend in the direction presenting the least resist- 
ance, and generally empty themselves unaided. The most fre- 
quent point of escape is into the posterior cul-de-sac of the vagina, 
or, if from either broad ligament, a little to one side of and pos- 
terior to the cervix. These abscesses rupture almost as often into 
the rectum, and with less frequency into the bladder. Occasion- 
ally the abscess may discharge into the intestines, in consequence 
of some adhesion, or it may follow the course of the psoas muscle 
and open into the groin. It is the least likely to rupture into 
the peritoneal cavity, since it requires so little irritation to produce 
adhesive inflammation of this membrane that it would be pro- 
tected in advance. 

4 'Should this accident occur, the shock would necessarily be 
great, fresh inflammation would be excited, and there could be no 
safety for the patient unless it proved the means by which the pus 
could again become encysted. 

"In rare instances, the pus may pass from the pelvis through 
either sciatic foramen, and burrow under the glutei muscles, or in 
the neighborhood of the hip joint. In many instances the escape 
of pus will continue only for a limited time, and, as the point of 
rupture is generally at the most dependent portion, the abscess is 
kept empty, its cavity shrinks, the walls adhere, and the discharge 
gradually ceases. The symptoms of blood-poisoning rapidly dis- 
appear, and the restoration to health is unobstructed. 

"Under other circumstances, the hectic fever and blood-poi- 
soning increase, and the discharge becomes more abundant. This 
occurs when the walls of the abscess happen to be so thick that 
they cannot be brought into contact, so that its cavity cannot be 
reduced after the escape of its contents. The whole interior then 
becomes a pus-secreting surface, and the disease proves a serious 
hindrance to the recuperative powers. Under no other circum- 
stances does a woman show to greater advantage her natural tena- 
city of life and powers of endurance."' 

Dr. Emmett says he has seen • * this drain kept up for two 
years, and with a degree of hectic and emaciation unequalled in 
the course of any other disease, and yet recovery take place. " He 
has met "with several instances where a collection of pus had 
become saculated, and without producing any constitutional dis- 
turbance, had remained in this condition for years, as I had every 
reason to believe from the history of the cases. An accumulation 
of pus in the neighborhood of the uterus, with thickened inflamed 
tissues about it, has been frequently mistaken for a fibroid with a 
suppressed recent attack of cellulitis.'' 



376 A TEXT-BOOK OF GYNECOLOGY. 

Diagnosis. — The following conditions arc most likely to be 
mistaken for pelvic cellulitis : — 

Uterine fibroids. — Here the diagnosis is usually easy, unless 
the tumor is inflamed, and lies low in the pelvis. Ordinarily the 
mode of inception of fibroids, their freedom from pain and tender- 
ness, and their distinct connection with the uterus, will suffice to 
distinguish them from a cellulitic deposit, which is accompanied 
by directly the opposite conditions, and which has the appearance 
of firm attachment, like a bony growth, to the walls of the pelvis. 

Hematocele. — This condition occurs suddenly, and often with 
hemorrhage. The symptoms are especially violent, and the pallor, 
coldness and syncope show the loss of blood, while the tumor lies 
in Douglas's cul-de-sac pressing the uterus forward, while the exu- 
dation of peritonitis is usually to one side of the uterus. But the 
location of the tumor is not conclusive, the history of the case 
and the character of the tumor being the chief guide. 

Extra-uterine pregnancy. — This may bo mistaken for celluli- 
tis, but the presence of some of the ordinary signs of pregnancy, 
and the gradual development and change in character of the tumor 
will usually clear up the diagnosis. 

Ovarian and Parovarian cysts sometimes resemble a cellulitic 
exudation, but their higher position, their mobility, and their 
different consistence will usually serve to distinguish them. If, 
however, they are low down and confined in one position, and then 
become inflamed, the diagnosis will be difficult. 

Pelvic Peritonitis. — Dr. Thorburn gives the following differ- 
ential table between these two similar and often conflicting affec- 
tions (1) :— 

Pelvic Peritonitis= Pelvic Cellulitis. 

1. Causation. — Many causes 1. Causation. — Local injuries, 
common to both. General shock, especially in labor, sepsis from local 
general septicemia, and gonorrhea affections or surgical proceedings 
more frequent. more common. 

2. Acute, Symptoms. — Tempera- 2. Acute Symptoms. — Tempera- 
ture high in general septicemia, tare averages higher. Pulse varies, 
lower in slighter forms. Pulse rapid. Pain often less. Tenderness chiefly 
Pain severe, diffused, abdominal. pelvic, generally lateral. Vomiting 
Tenderness chiefly hypogastric, and tympanitis absent. One thigh 
rarely lateral, vomiting and tympa- often flexed, afterward adducted or 
nitis common. Both thighs some- abducted. 

times flexed, 

3. Local Swelling. — Fluid, and 3. Local Swelling. — Distinct iu- 
almost indistinguishable at first. tra-pelvic swelling almost from the 
Site all around the uterus, but tend- first. Site varies, never symme- 
ing to distend Douglas' pouch sym- trical behind uterus, most often in 
metrically behind. Subsequent ex- one broad ligament, or at isolated 
tension upward into peritoneal points, e.g., behind bladder, in one 
cavity. utero-sacral ligament, or in pelvic 

glands. Extension occurs along 
course of connective tissues. 



1) Diseases of Women, American Edition, IBS?, p. 79? 



PELVIC CELLULITIS. 377 

4, Uterus fixed early in normal 4. Uterus generally displaced 
position or pushed forward. laterally, often flexed, fixation some- 
times less complete. 

5. Cervix may be normal, or 5. Cervix often apparently 
apparently shortened behind or all shortened at one side. 

round. 

In addition to the points of differentiation given, I would call 
attention to the aggravation in peritonitis which usually occurs at 
each menstrual period, and to the fact that in the latter there is no 
distinct tumor in the beginning, but a hardening of the whole 
pelvic roof. 

Prognosis. — Pelvic cellulitis is always to be regarded as a 
serious disease, and the prognosis should be guarded as to a com- 
plete recovery. It may run a very acute course, and result in 
recovery by resolution or suppuration, or it may become chronic 
and be indefinitely prolonged. The tendency is to recovery, and 
comparatively few cases die, but the slow resolution of the products 
of inflammation, and the pathological conditions brought about by 
these deposits, often render the patient's life a burden to which 
death would be preferable. Cases occurring after parturition and 
those complicated with peritonitis offer the most unfavorable 
prognosis. 

Treatment. — If called to an acute case during the first stage 
the patient should be placed in bed at once, and admonished to 
keep perfectly quiet. The indicated remedy — probably either 
Aconite, Belladonna, orVeratrum vir., should be prescribed, at the 
same time dry heat should be applied to the extremities, using, if 
possible, the hot-water bag, or bottles filled with hot water. Moist 
heat should then be applied to the abdomen, which is best done by 
the use of a linseed or cornmeal poultice, the moisture being 
retained by means of waxed paper or oiled silk. In addition to 
this treatment, especially if the symptoms are very severe, the hot 
water vaginal douche should be employed. This method was first 
practiced and advised by Emmett, who says "it is the only means 
we possess for aborting an attack of cellulitis, which it will do, if 
thoroughly employed at the beginning." 

There seems to me but one objection to the use of this method 
in the first stage of cellulitis, and that is the necessary disturbance 
and movement of the patient, who should be kept absolutely 
quiet. But this objection is apparently overcome in the good 
results that are claimed. According to Emmett, (1) "the injection 
should be continued literally for hours, if possible, and be repeated 
at short intervals." The best rule is to continue the injection 
until reaction has fully taken place, by which time the fever will 
have subsided, and a free action of the skin will have been estab- 



1) Op. Cit., p. 262. 



378 A TEXT-BOOK OF GYNECOLOGY. 

lished. Whenever it is possible to prolong this action of the skin 
by the use of the liquor ammonii acetatis, or by any other rem- 
edy, it should be done. Nothing would be better than a Kussian 
bath if it were available without involving the risks of exposure, 
and without entailing additional pain from the movements which 
would be necessary. The use of the hot water is usually very 
grateful, and, as it evaporates under the bedclothing, the action of 
the skin is thereby much increased. 

"The continued action of the hot water is to stimulate the 
circulation in the pelvis, so that the local congestion may be 
relieved before nature attempts to do so by the exudation of serum 
into the surrounding tissues. With this view, it will be seen that 
an increased action of the skin must be most beneficial, and should 
be kept up as long as possible." 

The general directions for giving a hot water vaginal injection 
have already been presented in detail in a previous chapter, to 
which the reader is referred. 

Should the attack prove not to have been aborted, or should 
the physician be called only after the stage of effusion has set in, 
he will, with the exception of the internal remedy, be called upon 
to employ about the same method of treatment as in the congest- 
ive stage. Absolute rest in the recumbent posture should be 
enjoined, the application of heat and moisture should be con- 
tinued, and the hot water vaginal injections employed persistently 
twice a day, morning and evening, at least a gallon of water being 
used at each injection. Emmett says that in this stage, while the 
hot water can no longer act as a prophylactic, "it may indirectly 
stimulate the absorbents and diminish the pelvic circulation some- 
what, and soothe the general system by temporarily relieving the 
local irritation. It thus gives great comfort, and is most useful in 
inducing sleep, when employed after the patient has been prepared 
for the night." 

In chronic cases, when, for any reason, the vaginal douche 
can not be used, the patient should use hot sitz-baths at least twice 
each day, and in such ■ cases also when the poultices referred to 
become disagreeable to the patient, or seem to do no good, a piece 
of flannel may be wrung out in hot water containing either Acon- 
ite, Arnica, or Hamamelis, and applied double over the abdomen, 
this again being covered with oil silk. Should constipation be 
present, the bowels should be kept clear by the daily use of ene- 
mata, which must be administered very carefully, even the disten- 
sion of the rectum by the enema sometimes causing great pain. 
At all events no fecal mass should be allowed to accumulate, and 
if for any reason the enemata do not suffice, a few ounces of 
warm flax-seed tea or oil should be thrown into the rectum, and 



PELVIC CELLULITIS. 379 

then the feces be gently removed with the finger. Cathartics are 
never to be employed. The food should be light and nutritious. 
Milk, eggs, beef -extracts, and other concentrated foods, which, 
while nourishing, are possessed of little fecal residuum. As far as 
the season and circumstances will permit, the patient should be 
allowed the benefit of fresh air and sunshine, but at all times be 
well protected from exposure by wearing flannel next the skin, 
except during very hot weather, and this exception should not be 
made in those cases where the patient is able to be out of doors. 
Electricity has been highly recommended for the relief of the pain 
in chronic cellulitis, and for promoting the absorption of the 
exudation. In this connection the reader is referred to Chapter 
XXI for Dr. Apostolus method of treatment by intra-uterine gal- 
vano-cauterizations. Should the exudation fail to be absorbed, 
and suppuration ensue, the case becomes one of pelvic abscess, 
the treatment of which will be considered in a separate chapter. 

By no means of least importance in the treatment of pelvic 
inflammations is the selection of the appropriate homeopathic rem- 
edy. While the dominant school of medicine are compelled in 
this disease, as they are practically in all others, to depend mainly 
upon Opium and Quinine, we have at our command remedies which 
may cover every individual phase of the disease, and not only 
assist greatly in controlling the primary congestion and aborting 
the attack, but also in promoting absorption of the exudation after 
that has taken place, and saving the patient from the evil conse- 
quences of a pelvic abscess. Among the most important remedies 
are the following : — 

Aconite. — This is usually the first remedy called for, and is 
of use only in the congestive stage, when there is high fever, 
rapid pulse, great restlessness and anxiety. Nearly all recent old- 
school authorities recommend Aconite in this stage of the disease. 
Hart and Barbour say (1) it "should be given (in drop doses) every 
quarter of an hour until the pulse is reduced and sweating brought 
on." 

Veratrum Viride. — This remedy is also useful in the con- 
gestive stage, and will generally cover those cases where Aconite 
is not indicated. The congestion is very strong, the pulse quick, 
full and incomprehensible, and there is not the characteristic rest- 
lessness and anxiety of Aconite. It is often indicated in cases 
occurring in fullblooded, plethoric women. According to Dr. 
Ludlam (2) it is more especially useful in "lying-in and nursing 
women, and in those in whom an erysipelatous inflammation either 



1) Manual of Gynecology, p. 158. 

2) Arndt's System of Medicine, p. 505. 



380 A TEXT-BOOK OF GYNECOLOGY. 

alternates with, or predisposes to, pelvic cellulitis. It has a wonder- 
ful power to control and regulate the vascular movements, to 
equalize the circulation through the areolar tissue within the pelvis, 
as well as in other parts of the body, and to stamp out a local con- 
gestion that would almost inevitably result in an inflammatory 
exudation. It may be given in the second or third decimal dilu- 
tion, and in urgent cases the dose should be repeated every half 
hour for two or more hours, after which it may be given less often." 

Belladonna. — This remedy is more apt to be indicated in 
the latter part of the stage of congestion, when the former reme- 
dies have failed to abort the inflammation and effusion is about to 
take place, and in cases resulting from or complicated with erysip- 
elas. The face is flushed, the carotids throbbing, and the pulse 
full and bounding. The abdomen is distended and very sensitive 
to touch, and violent cutting colicky pains come and go rapidly. 
There may be retching, vomiting, anxiety and dyspnoea. 

Arnica is useful in cases of traumatic origin. 

Bryonia. — Most useful in the first part of the stage of exuda- 
tion; stitching, lancinating pains in the abdomen, worse from the 
slightest motion; tongue white and dry; great thirst; constipation. 

Colocynth. — Abdomen distended and painful; violent cut- 
ting pains causing the patient to bend double, occurring in parox- 
ysms. Dr. Ludlam (op. cit.) says Colocynth will frequently 
control the pain and abort a coincident peritonitis, especially when 
it occurs in the region of the ovaries, or in the visceral peritoneum 
within the pelvis or the abdomen. It has a marked effect to 
prevent the serous effusion into the peritoneal cavity, which some- 
times complicates severe attacks of pelvic cellulitis. 

Apis. — The action of Apis upon the cellular tissues is more 
characteristic than that of any other remedy, and its power to 
cause absorption of cellular effusions is proverbial. It is especially 
indicated when the abdomen is distended and sensitive, with burn- 
ing, stinging pains in the uterus or ovaries, oedema of the extremi- 
ties, absence of thirst and scanty urination. 

Mercurius. — This is one of our best remedies to promote 
resolution after exudation has taken place, and generally follows 
well after Bryonia. Some prefer the Mercurius corr., especially 
in peritonitis. Dr. Ludlam recommends the Mercurius iod. The 
special indications of Mercurius are too numerous to repeat. 

Rhus Tox is useful where there is a tendency to typhoid; 
tongue red at the tip; great restlessness, changing position contin- 
ually though it increases the pain. 

Arsenicum. — The patient rapidly emaciates; great prostra- 
tion, adynamia; nervous restlessness; drinks often, but little at a 
time. 



PELVIC CELLULITIS. 381 

Antimonium Tart. — This drug, according to Dr. Ludlam, 
"has a specific influence in removing patches of induration which 
are neither very extensive nor very firm in their texture. In these 
limited tumors, especially if the patient is of good general health, 
it seems to take hold in some such way as it does in cases of 
areolar hyperplasia of the uterine cervix. By its persistent use in 
the third decimal trituration, repeated three or four times a day, 
these indurations begin to melt, and finally disappear." 

Terebinthina. — According to the same author, "in cases of 
pelvic cellulitis following circumscribed peritonitis, ovaritis, or 
typhlitis, the Terebinth may be given with a good result in the 
second decimal trituration. If the lesion involves the bladder and 
implicates micturition, the indication is also a good one." 



CHAPTER XLVIIL 



PELVIC ABSCESS. 



This condition is usually described in connection with pelvic 
cellulitis, but as it is very liable to arise from other causes quite 
distinct from either pelvic peritonitis or pelvic cellulitis, it is emi- 
nently proper that it should receive separate consideration. 

Definition. — A collection of pus originating within the 
pelvis. This does not include lumbar, psoas and other abscesses, 
which, while originating outside the pelvis, sometimes involve the 
pelvic tissues. 

Etiology. — Pelvic abscess most often follows as a sequel of 
pelvic cellulitis. It may likewise be a sequel of pelvic peritonitis, 
metritis, salpingitis or ovaritis. It may also result from the suppu- 
ration of an hematocele, an ovarian cyst, an extra-uterine embryo, 
or, from the breaking down of tuberculous material deposited in 
any of the tissues of the pelvis. 

Symptoms. — These are such as usually indicate suppuration 
in other parts. Rigors, fluctuating high temperature, throbbing 
pain, hectic fever and profuse sweats are present in proportion to 
the extent and acuteness of the suppuration. Bi-manual examina- 
tion reveals a soft, fluctuating mass, located in the place which was 
formerly the seat of inflammation. When the abscess has followed 
a cellulitis, there will have been a hard exudation in the parts. 
Sometimes the soft, fluctuating mass is surrounded by a hard exu- 
dation which still remains. 

Diagnosis. — If the above symptoms follow a history of in- 
flammation, there is usually little doubt of the diagnosis, but 
should there be any uncertainty, and the case be such as to require 
immediate interference, the aspirator may be used to establish the 
character of the tumor. 

Prognosis. — This depends largely upon the location at which 
rupture takes place. Should this occur upon the abdominal wall, 
or within the vagina, with a free discharge, the probabilities are 
favorable to recovery. Should the abscess open into the rectum, 
it is less favorable, and still less so when the bladder is the point 
of its exit, but a rupture into the peritoneal cavity is the most 
unfortunate, giving rise immediately to a rapidly fatal peritonitis. 
Sometimes an abscess establishes two points of exit, which renders 
the prognosis less favorable. Sometimes the discharge continues 



PELVIC ABSCESS. 383 

for a long time; or the sinus closes, only to re-open at the same 
or some other point, until finally the patient succumbs from the 
consequent exhaustion. In exceptional cases death results from 
embolism or septicaemia. 

Treatment. — One of the most important features in the 
treatment of pelvic abscess is to sustain the strength of the patient, 
that she may be better able to stand the tax upon her vital forces 
which the continued process of suppuration involves. She should 
be supplied with the most nutritious diet, such as beef, eggs, milk, 
etc. ; and should take malt liquors, or whiskey, or brandy in case of 
great prostration. The remedies most likely to be needed for the 
constitutional symptoms are Arsenicum, Cinchona and Iodine, 
according to indications. For the suppurative process: — 

Hepar Sulph. — When the process is enevitable, and we wish 
to hasten it. 

Mercurius. — This is one of our most valuable remedies in 
suppurative conditions, especially when the nutrition is seriously 
impaired. It does not promote suppuration as does Hepar, nor 
check it as does Silicea, but it seems to assist in keeping the pro- 
cess circumscribed, and causing its absorption. It is therefore 
most useful to avert threatening suppuration before it has taken 
place. 

Silicea. — When the process of suppuration is slow and long 
lasting, causing a very serious drain upon the system, and when 
there are fistulous openings into other organs or parts. 

Surgical Treatment. — There exists much difference of 
opinion as to the proper surgical management of a pelvic abscess. 
Some think the pus should be evacuated early, even though it be 
deep-seated and give rise to no urgent symptoms. Others think 
it should be left to nature entirely, being allowed to u point" and 
open at its pleasure. I do not think it is safe to follow either of 
these opinions. The abscess should never be opened until there 
are symptoms which indicate its necessity; whereas, on the other 
hand, the effort should never be left to nature unless we are pretty 
sure from appearances that the abscess promises to u point" in a 
location favorable to its discharge. There can be no fixed rule, 
and the judgment of the surgeon must decide in each case. In 
the event of its being advisable to open the abscess, the puncture 
should usually be made at the spot where it has a tendency to 
"point," if that can be discovered; if not, a point should be 
selected from which the abscess can be most easily reached through 
the vagina or abdominal w T alls, the vagina being by far the safer 
location, though in some instances the tumor is located so far up 
that it can only be reached from the abdominal surface. Should 
it be decided to reach the abscess through the roof of the vagina, 



384 A TEXT-BOOK OF GYNECOLOGY. 

the patient should be etherized, placed upon her right side, and a 
Sims' speculum introduced. If it is found that the pus is prob- 
ably contained in a single cavity, and there is no evidence of 
decomposition, or symptoms of septicaemia, the abscess may be 
evacuated by aspiration, but as a rule the use of the aspirator in 
the treatment of pelvic abscess has not given satisfaction. There 
is danger that clots of blood, sloughs of connective tissue, and 
shreds of lymph, too large to pass through the needle, will be left 
behind, and keep up the process of suppuration. 

If it is decided to open the abscess with a knife, a grooved 
director or exploring needle is pushed into the abscess cavity at 
some point as remote as possible from the pulsating vessels which 
may be discovered. As soon as pus appears in the groove a 
tenotomy-knife is to be passed along the director, and the opening 
enlarged by cutting in opposite directions until it is capable of 
admitting the index finger. 

After introducing the finger into the cavity any partitions 
which may be felt are to be broken down. A full-sized drainage 
tube should then be introduced, and secured in position by stitch- 
ing it to the vaginal wall. Through this tube the cavity may be 
washed out daily, or oftener, by a gentle stream of pure water, 
or the water may be made stimulating and disinfectant by a solu- 
tion of the bichloride of mercury, 1:4000, or of Lugol's iodine 
somewhat diluted, or the hydrogen peroxide may be used, which, 
from its innocuous character and its remarkable germicidal pro- 
perties, is, I am satisfied, destined in a great measure to supplant 
the irritating and more or less dangerous disinfectants which are 
now used in connection with pus-discharging surfaces. 

Should fungoid masses be discovered within the abscess it will 
be necessary to introduce the finger or a dull curette and scrape 
them away. In case the abscess is located so high up that it 
cannot be reached from the vagina, or if for any other reason the 
vaginal operation is inadmissible, resort must be had to abdominal 
section, as proposed and successfully practiced by Mr. Lawson 
Tait. 

An incision two inches in length is made through the linea 
alba, midway between the umbilicus and pubes, and after all 
bleeding is stopped the peritoneal cavity is opened and the abscess 
aspirated; then a free incision is made into the abscess wall, and 
its edges are carefully stitched to the edges of the abdominal 
wound. A drainage tube of glass or rubber is then inserted, and 
the cavity is daily washed with plain water. 

Sometimes the abscess wall is adherent to the abdominal wall 
in front. In such cases the treatment is more simple — evacuation 
of its contents and drainage. In other cases the accumulation of 



PEL VIC ABSCESS. 385 

pus is small and lies deep in the pelvis. Here the work inside the 
abdomen will consist in separating the attachments of adherent 
viscera and in ligating and removing the diseased appendages. 
While doing this the abscess-cavity may be ruptured and its con- 
tents discharged into the peritoneum. The pus should then be 
carefully taken up by sponging, and the pelvis washed scrupulously 
clean with warm water, and then drained. 

Of this operation Mr. Tait says (1): — "My general conclusion 
from these cases is that the opening of such abscesses by abdominal 
section is neither a difficult nor a dangerous operation; that re- 
covery is made in this way more certain and rapid than in any 
other; and that in future I shall always advise an exploratory 
incision where I am satisfied there is an abscess which cannot be 
reached nor emptied satisfactorily from below." 

Sometimes cases are found in which the abscess has already 
discharged at one or more points and sinuses remain which it is 
desirable to close. It may then be necessary to make a counter- 
opening through the vagina. In order to best accomplish this, 
Simpson recommends that a large probe or sound be passed 
through some opening above the pelvic brim, down into the pelvis 
until its point is felt by the side of the womb in the upper part of 
the vagina. Then, cutting upon this as a guide, at the most de- 
pendent point of the abscess-cavity, a counter-opening is made. 

Cases of this kind are usually old chronic ones and often 
present many grave difficulties in their treatment, the management 
of which cannot be established by fixed rules, but must depend 
entirely upon the conditions found in each case. Sometimes the 
sinuses may be closed by the application to their walls of a strong 
tincture of Iodine, while in other cases all treatment fails and final 
resort must be had to abdominal section and the removal of the 
diseased appendages. At all times the treatment of pelvic abscess 
requires the exercise of the most careful judgment, and there is 
usually no disease to which woman is subject where the patience 
and skill of the surgeon are more severely taxed. 

i) Diseases of the Ovaries, 1883, p. 351. 



CHAPTER XLIX. 



PELVIC HEMATOCELE. 



Synonyms. —Uterine Hematocele. Retro-uterine Hematocele. 
Peri-uterine Hematocele. Pelvic Hematoma. 

Definition.— An accidental collection of blood within the 
pelvis either above or below the pelvic peritoneum. Winckel (1) 
defines pelvic hematocele to be "an encapsulated extravasation of 
blood into the true pelvis." He, with some other authors, holds 
that to constitute hematocele the effusion must be fixed in place by 
firm coagulations or surrounding inflammatory exudations. Hart 
and Barbour define pelvic hematocele to be ' w an effusion of blood 
into the pelvic peritoneum, enclosed either by anatomical struc- 
tures, or previously existing inflammatory adhesions" (2). 

Schrceder refuses to accept as pelvic hematocele any collection 
of blood within the pelvis save that which Nelaton, who first 
described hematocele, defined as "the formation of a tense bloody 
tumor in Douglas' cul-de-sac, which crowded the uterus against the 
symphysis pubis" (3). He therefore adopts only the term 'retro- 
uterine, ' and, with Voisin, Bernatz and others, considers all cases 
as intra-peritoneal. Simpson, on the contrary, considered that a 
hematocele was usually formed by hemorrhages taking place out- 
side of the peritoneal sac. I think, however, that it will best serve 
all practical ends to treat as pelvic hematocele all effusions of blood 
taking place within the pelvis, whether in the peritoneal cavity, or 
under the peritoneum, or within the connective tissue of the pel- 
vis. It must be borne in mind, however, that pelvic hematocele 
is not a disease, but only a symptom of some previously existing 
pathological condition. 

Pathology. — As a rule, a hematocele is located in Douglas' 
cul-de-sac, and displaces the uterus forward. Should the hemor- 
rhage be profuse, the blood may reach above and cover the broad 
ligaments and uterus. The effusion may take place into the vesico- 
uterine pouch, but such instances are rare. Sometimes an intra- 
peritoneal effusion of blood may occur without either the posterior 
or anterior pouches being filled. In such cases there have probably 
been prior adhesive inflammations which have obliterated or closed 



1) Diseases of Women, p. 610. 

2) Manual of Gynecology, p. 165 

3) Ziemssen, Vol. X, p. 468. 



PEL VIC HEM A TOCELE. 387 

these parts. Many authors hold that in most instances, at least, 
the encapsulating membrane is thus formed by previous inflamma- 
tory attacks before the effusion takes place, but this is hardly 
probable, for it is known that blood effused into serous cavities 
encysts itself within a few hours, being enveloped by lymph which 
creates a false membrane. Extra-peritoneal effusion, sometimes 
called hematoma, involve the intra-cellular tissues below the peri- 
toneum, forming a solid mass, which sometimes pushes the 
peritoneum to such an extent as to give an appearance of intra- 
peritoneal effusion. Indeed this may go so far as to cause a rup- 
ture of the peritoneum, and, blood passing into the peritoneal 
cavity, the hematocele becomes both extra- and intra- peritoneal in 
character. Sometimes, if the blood is poor in fibrin, coagulation 
does not occur, the blood remaining in a fluid state and becoming 
absorbed ; or, under some circumstances it may become purulent. 
In case coagulation takes place, as is usually the case, the mass 
becomes very hard, and is finally absorbed ; or, suppuration may 
follow and give rise to pelvic abscess. 

Etiology. — Hematocele is most apt to occur between the ages 
of twenty-five and thirty-five, when the generative organs are most 
active, but it has been known to occur in women who have passed 
the menopause. It most often occurs in women who have borne 
children rapidly, though it may also occur in the sterile, but very 
seldom in those who are unmarried. It is said to constitute from 
five to seven per cent, of the diseases of women. It is therefore 
evident that the age of ovarian activity is a predisposing factor, as 
is also the married state and child-bearing. Purpura, scorbutis, 
chlorosis, plethora and anaemia are the blood states which may be 
said to predispose to hematocele. Chronic ovarian disease, pelvic 
peritonitis, and the hemorrhagic diathesis may also be included in 
the predisposing causes. The exciting causes are sudden checking 
of the menstrual flow ; violent exercise during menstruation ; vio- 
lent coitus, especially during menstruation; blows or falls; obstruc- 
tion of the cervical canal ; obstruction of the oviducts. 

A study of the causes of hematocele necessarily involves a con- 
sideration of the sources from which the blood, of which the 
effusion consists, may have been derived. These are usually three 
in number. 1. Rupture of vessels in the pelvis. 2. Reflux of 
blood from the uterus or tubes. 3. Transudation of blood in 
consequence of dyscrasia or pelvic peritonitis. According to 
Thomas (1) the following table gives the special and most frequent 
sources of the hemorrhage : 

1. Rupture of blood-vessels in the pelvis : 
Utero-ovarian ; 



1) Pepper's System of Medicine, Vol. IV, p. 341. 



388 A TEXT-BOOK OF GYNECOLOGY 

Varicose veins of broad ligaments ; 
Vessels of extra-uterine ovisac. 

2. Rupture of pelvic viscera : 
Ovaries ; 

Fallopian tubes ; 
Uterus. 

3. Reflux of blood from the uterus : 
Menstrual blood. 

4. Transudation from blood-vessels : 
Purpura ; 

Scorbutus ; 

Chlorosis ; 

Hemorrhagic peritonitis. 
"It is then clear," says Thomas, "that the mere presence of 
a large clot of blood in the pelvis, apart from general symptoms, 
is a matter of very doubtful significance, since on the one hand it 
may be the result of a mere regurgitation of menstrual blood due 
to imperviousness of the cervical or tubal canal, or, on the other, 
of the rupture of a Fallopian tube, which has become the nidus of 
an extra-uterine foetus. " 

Symptoms. — It is very seldom that pelvic hematocele occurs 
suddenly in women who have been in good health. I have never 
seen a case in which there had not previously been some disturb- 
ance of the generative organs, and usually irregular or delayed 
menstruation, and quite as often there had been for months, and 
even years, evidences of decided blood dyscrasia. In such the 
collection of blood may have taken place slowly, and the symptoms 
developed in a corresponding manner. But in the majority of cases 
the hemorrhages occur suddenly and without warning, producing 
violent shock and quickly developing symptoms of the most intense 
character, the patient rapidly succumbing, and death resulting 
within a few hours. Such cases are the result of a profuse, free 
hemorrhage into the peritoneal cavity, and are " non-encysted, " 
there having been no time for the lymph exudation to form and 
"establish the encapsulation, on account of "the terrible suddenness 
and severity of the blow struck at the vital powers." 

Dr. Barnes has called these cases "cataclysmic," and they are 
supposed to be most frequently the result of the rupture of an 
extra-uterine gestation sac, or the bursting of ovarian vessels. It 
must be remembered, therefore, that all cases do not present the 
same intensity of symptoms, the severity depending upon the 
suddenness of the attack, the amount of blood extravasated, and 
the general condition of the patient. Thus the cases may vary 
from those in which there is but a slight hemorrhage, and so few 
symptoms that the nature of the case may not be recognized, to< 
the rapidly fatal cases above described. 



PELVIC HEMATOCELE. 389 

Usually an attack occurs at or near the menstrual period, and 
most frequently follows on some unusual exertion. The patient 
complains suddenly of an intense, excruciating pain about the 
region of the pelvis; this is soon accompanied by more or less 
vomiting of bile and rapidly followed by symptoms of shock and 
collapse, pallor, faintness and exhaustion, coldness of the extremi- 
ties, cold sweat, rapid, feeble pulse, and hiccough. Emmett says 
that ; ' the pain is beyond every other symptom the most charac- 
teristic, and is as excruciating as if the tissues were being torn 
apart with violence.'" Soon enlargement of the abdomen may 
appear, and at the same time there is much disturbance of the 
bladder and rectum from pressure of the accumulated blood, the 
temperature falls below normal, and there is often menorrhagia. 
Death may result within a few hours; but in most cases there is 
within this time a more or less decided reaction, which may result 
in convalescence. Or, again, a first hemorrhage may be followed 
by a second, with a more profound collapse, and speedy death. 
In other cases the presence of the blood in the peritoneum or cel- 
lular tissue may give rise to inflammation, with its usual attendant 
symptoms, and be followed either by absorption and recovery, or 
by pelvic abscess with its usual history. 

Physical exploration at an early stage will reveal a soft, boggy, 
obscurely fluctuating mass in the vagina, usually, but not always, 
posterior to the uterus. At a later stage this mass gives to the 
touch the sensation of a smooth, dense, solid body. The uterus is 
usually found pressed upward and forward toward the pubes, and 
generally to one side or the other, where the fundus can readily 
be traced by bi-manual examination. According to Emmett (1) a 
distinct mass is ' ' rarely felt, and a displacement does not occur 
except when the fluid is confined to a limited space, or when 
extravasated into the cellular tissue beneath Douglas' cul-de-sac. 
When the blood is poured out rapidly into the peritoneal cavity, 
it will naturally gravitate into Douglas' pouch. But under other 
circumstances a clot may form about the seat of the rupture, so 
that nothing can be detected in the cul-de-sac for an indefinite 
time after the occurrence of the accident. If peritonitis has not 
occurred, and the blood is thrown out rapidly, it will accumulate, 
as any liquid would do, and fill up all the space about the uterus, 
without displacing the organ. Cases are, however, frequently 
met with in which it is exceedingly difficult to determine the exact 
locality of the hematocele, as to its being within or without the 
peritoneal cavity. But with care the diagnosis may generally be 
made out, even in difficult cases. An accumulation of the cellular 
tissue of the pelvis cannot lift the peritoneum to any great extent 



1) Op. Cit., p. 226. 



390 A TEXT-BOOK OF GYNECOLOGY. 

without rupture; but after the blood escapes into the peritoneal 
cavity it will be impossible to distinguish whether it originally 
formed there or not. An hematocele within the peritoneal cavity 
may slowly enlarge, and extend out of the pelvis on the side of 
rupture to above the line of the umbilicus, although it may have 
had its beginning in a rupture in the cellular tissue. But, on the 
other hand, if the mass is felt extending low in the pelvis, the 
probability is far greater that the effusion is confined to the 
cellular tissue." 

In case the extravasation is within the peritoneum, the tumor 
may be discovered by palpation through the abdominal walls, but 
not if the blood lies oelow the peritoneum. 

Diagnosis. — Pelvic hematocele is liable to be confounded 
with pelvic cellulitis; pelvic peritonitis, followed by enclosed serous 
effusion in Douglas' cul-de-sac; pelvic abscess; fibroid on the 
posterior wall of uterus; retroversion; extra-uterine pregnancy, 
and displaced ovarian cysts. 

The two first named are most liable to be mistaken for hemat- 
ocele, but the sudden onset, the absence of the symptoms of acute 
inflammation, and the symptoms of shock and collapse from loss 
of blood, which are present in the latter, are all-sufficient to make 
the diagnosis. Then, too, it should be remembered that the tumor 
in cellulitis is hard at first and afterward softens, whereas that of 
a hematocele is soft and fluctuating at first and gradually hardens. 
The tumor of cellulitis forms slowly; is tender from the first, and 
does not press the uterus forward against the pubes. Dolbeau 
gives two important diagnostic points: — 

' ' The excessive pallor of the face, so important a symptom 
in hematocele, is never seen in pelvic peritonitis. 

" The direction of the cervix forward belongs exclusively to 
hematocele." 

Pelvic abscess shows plainly the history of a prior inflamma- 
tion, while the present symptoms are those of suppuration rather 
than of a sudden loss of blood, and the tumor grows soft instead 
of becoming harder. 

Retroversion of the uterus, especially in the gravid state, is 
sometimes mistaken for hematocele, but a careful bi-manual exam- 
ination taken together with the absence of anaemic symptoms is all 
that is required to correct the mistake. 

Fibroids are of slow and painless growth, are hard and irreg- 
ular in form, and firmly attached to the uterus, and pull the latter 
backward, rather than push it forward against the pubes. 

Extra-uterine pregnancy, by a rupture of its sac, produces 
hematocele in its most violent and fatal form. So, while it is seldom 
necessary to differentiate between these conditions it is important 



PELVIC HEMATOCELE. 391 

to decide, if possible, whether extra-uterine pregnancy is present or 
not. The symptoms of gestation, together with an empty uterus, 
and the knowledge of the previous presence of a definite tumor, are 
reliable indications. But if an early extra-uterine fcetation bursts 
into the cavity of the peritoneum, as is usually the case when the 
ovum is developed in the Fallopian tube, its existence can only be 
surmised, but cannot be demonstrated. 

Displaced ovarian cysts have the history of a comparatively 
slow, painless growth, remain continuously, as at first, a soft 
fluctuating mass, and present no symptoms of intensity or severe 
hemorrhage. 

Prognosis. — When the effusion is very large death usually 
results within a few hours from loss of blood and the shock caused 
by the sudden invasion of the peritoneum. If death does not 
occur, recovery by absorption generally follows; or, peritonitis 
setting in, the usual course of that disease is followed, the final 
history often being that of a pelvic abscess. When the extra- 
vasation is slight, or is well encapsulated, or is extra-peritoneal in 
character, the prognosis is favorable. 

Thomas says that as a rule the prognosis of hematocele u is 
decidedly favorable unless the surgical tendencies of the attending 
practitioner alter its natural inclination." I must confess that my 
own experience has not been very encouraging, the several cases 
that have come under my own observation having all been 
"cataclysmic, " death resulting in each case in from a few hours to 
as many days. 

Treatment. — While it may be impossible to foresee an attack 
of internal hemorrhage, yet when a woman is suffering from any 
of those peculiar blood states which are known to predispose to 
hematocele, or if she have obstructive dysmenorrhea, or varicose 
veins with profuse and painful menstruation, she should be sur- 
rounded by all possible safeguards against this unfortunate accident. 
Such women should avoid all violent exercise, traveling or exposure 
during or near the menstrual period, and sexual intercourse should 
be absolutely prohibited during that time, and at all times should 
be practiced with moderation and without violence, and in such 
cases the indicated remedy should be perseveringly administered. 
At the onset of the attack the patient should be placed in a recum- 
bent posture, absolute rest enjoined, and ice-bags applied to the 
abdomen. 

Emmett recommends a moderately tight abdominal band- 
age. Hot fomentations and poultices are to be avoided. If the 
patient is collapsed, stimulants should be used freely, and it 
may be required to give hypodermic injections of brandy or sul- 
phuric ether, but this should cease as soon as the temperature 



392 A TEXT-BOOK OF GYNECOLOGY. 

becomes normal, and the patient be placed at once upon milk, eggs, 
peptonized meats, etc. 

Old-school authorities recommend hypodermic injections of 
ergot as a vascular styptic. 

The relief of the agonizing pain which the patient suffers, 
incident to an attack of hematocele, becomes a matter of serious 
importance to those who are opposed to the use of Opium. But 
as the pain is due to a mechanical cause, and is not amenable to the 
usual homeopathic remedies, there seems to be no other way than 
to resort to the use of a palliative. In such cases I have never 
been able to withstand what seemed to me to be the instincts of 
humanity, and have always prescribed morphine for the relief of 
the pain. 

In cases where the pain is not so extremely violent as to make 
a palliative absolutely necessary, the remedy most frequently indi- 
cated is Ipecac, though often Aconite will be called for. Later 
Secale may be given. The remedies usually called for after reac- 
tion has set in are Arsenicum, Chininum, Chininum ars., Nuxvom., 
Ignatia, or Rhus tox, though other remedies may be demanded by 
the individual symptoms of the case. After inflammation is estab- 
lished, if it should occur, the course of treatment is essentially the 
same as for pelvic peritonitis. 

It now remains to notice the indications for or against surgi- 
cal interference. If it is evident that the attack is intra-cellular, 
it should not be interfered with, as no surgical procedure can 
compensate for the loss of the restraining influence of the pelvic 
fasciae or coverings. If the effusion is within the peritoneum, the 
question as to the propriety of surgical interference becomes a 
serious one. Most authors, however, favor non-interference, 
believing that experience has shown that nature does better with- 
out any surgical aid, whether the latter be by abdominal section, 
by puncture with the bistoury, or by aspiration. In case, however, 
it is quite evident that the hemorrhage is due to a ruptured extra- 
uterine sac, or if there be an ovarian tumor, or a diseased and 
occluded Fallopian tube, I believe that, unless such a procedure is 
especially contra-indicated, the proper thing is to operate by 
abdominal section. 

When suppuration has taken place and symptoms of septi- 
caemia are manifest, the accumulated blood, or pus and blood, 
should be evacuated by a free opening made at the safest point 
indicated, and the sac thoroughly cleansed by repeated washings 
with a weak solution of carbolic acid. 

But little can be expected from the administration of remedies 
after the hematocele has occurred, but should recovery take place 
a recurrence may be prevented by giving such remedies as the con- 



PELVIC HEMATOCELE. 393 

stitutional symptoms of the patient may demand; and indeed if 
death does not occur at once, remedies will do much toward bring- 
ing about an absorption of the effused blood. Those which are 
mostly to be relied upon for this purpose are : Apis, Arnica, 
Arsenicum, Chininum, Digitalis, Hamamelis, Kali iod., Mercurius, 
Phosphorus, Secale, Sulphur. 






CHAPTER L. 



AMENORRHEA. 

Definition. — Amenorrhea is an absence of the menstrual 
flow occurring at any time between puberty and the menopause, 
except during pregnancy and lactation, when such a condition is 
physiological. 

Varieties. — Amenorrhea occurs in two forms : — 1. Those 
cases where menstruation has never occurred, emansio mensium ; 
2. those in which it has ceased after having been established, sup- 
pressio mensium. In addition, the term partial amenorrhea has 
been used to designate a condition of scanty, tardy or irregular 
menstruation. The term vicarious menstruation is used to desig- 
nate a condition in which, in the absence of a discharge of blood 
from the uterus, there are periodic hemorrhages from other parts, 
such as the nose, lungs, etc. 

Pathology. — Amenorrhea is but a symptom of various exist- 
ing pathological states of the generative organs with which it may 
be associated, each of which is elsewhere considered. It may arise 
also from grave constitutional diseases, such as phthisis, etc. It 
is evident, therefore, that the condition itself can have no estab- 
lished pathology, nor is it probable that amenorrhea ever gives 
rise to pathological states, it being itself a result rather than a 
cause of the many constitutional diseases with which it is asso- 
ciated, and the existence of which has been erroneously attributed 
to the failure of the menstrual function. An exception should 
apparently be made in those cases where acute suppression of the 
menses occurs from exposure to wet or cold, the flow not resum- 
ing, and phthisis rapidly following. Yet, in such instances, there 
is no reason to suppose that the exposure might not have produced 
phthisis, even had there been no disturbance of the menstrual flow. 
Such cases are not uncommon. 

The wide range of pathological conditions liable to give rise 
to amenorrhea may be inferred from the following quotation from 
Dr. Thomas, who says that "for the proper performance of the 
menstrual function three elements must exist in a perfect state of 
integrity : 1st, the uterus, ovaries, and vagina must be perfect in 
form and vigor ; 2d, the blood must be in its normal state ; and 
3d, the nervous system governing the relations between the uterus 
and ovaries must be unimpaired in tone. Any influence disorder- 

394 



AMENORRHEA. 395 

ing one or more of these may check ovulation, the great moving 
cause of the function, preventing the degree of sympathetic con- 
gestion necessary for rupture of uterine vessels ; or oppose the 
discharge of blood which has been effused." 

Etiology. — In accordance with the above views, Dr. Thomas 
tabulates the causes of amenorrhea as follows : 

Abnormal states of organs of generation : 

Absence of uterus or ovaries ; 

Rudimentary uterus or ovaries ; 

Occlusion of uterus or vagina ; 

Uterine atrophy ; 

Pelvic peritonitis ; 

Atrophy of both ovaries ; 

Cystic degeneration of both ovaries. 

Abnormal states of the Mood : 

Chlorosis ; 

Plethora ; 

Blood states of phthisis ; 

Blood states of cirrhosis ; 

Blood states of Bright's disease, etc. 

Abnormal state of ganglionic nervous system : 

Atony from mental depression ; 

Atony from indolence and luxury ; 

Atony from want of fresh air and exercise ; 

Atony from constitutional diseases, as phthisis, etc. 

These abnormal conditions, together with the symptoms they 
produce, may be better studied under their individual headings, 
and need not be further considered here. 

Exciting Causes. — These operate only in cases of acute sup- 
pression, which may result from exposure to cold or wet just 
before or during the discharge, or from fright, grief, mental dis- 
tress, or any profound disturbing influence. 

Symptoms. — In chronic amenorrhea the symptoms are often 
only such as are characteristic of the pathological condition of 
which the amenorrhea itself is but a symptom, and are better con- 
sidered in connection with those conditions. 

Acute suppression may give rise to symptoms which, in char- 
acter and intensity, will vary from those of ordinary menstruation 
— backache, heaviness and weight, pelvic pains, etc. — to symp- 
toms of profound disorder, leading sometimes to severe and danger- 
ous diseases. 

Diagnosis. — The diagnosis of amenorrhea is self-evident, but 
the diagnosis of the pathological condition which produces it is 






396 A TEXT-BOOK OF GYNECOLOGY. 

often a matter of difficulty, and can only be accomplished by a 
thorough understanding of these respective states. Often the 
most important consideration is to determine whether or not the 
menses are absent from physiological causes — pregnancy or the 
menopause. Should the menses have ceased suddenly in an other- 
wise healthy subject, the usual signs of pregnancy — morning 
sickness, etc., — should be considered. It should not be forgotten 
that the menopause may occur at an early age, as also may 
puberty be delayed much beyond the usual time, which facts 
should enter into consideration in those cases in which menstrua- 
tion has ceased without apparent cause, or, where it has not ap- 
peared at the usual age, and where, in either instance, abnormal 
symptoms have not developed. 

Prognosis. — This depends upon our ability to remove the 
existing cause, and is usually favorable. Aside from cases result- 
ing from an absence or rudimentary condition of these organs, 
those which result from blood states or constitutional diseases are 
the most serious in their character. 

Treatment. — In the first place it is a safe and proper rule to 
follow that no case of amenorrhea requires treatment so long as it 
presents no positively morbid symptoms. Very frequently emansio 
mensium requires no treatment, but suppressio mensium and 
partial amenorrhea usually demand medical aid. 

The treatment invariably consists in ascertaining and removing 
the cause, whether mechanical or constitutional. 

For the treatment of those cases arising from abnormal states 
of the organs of generation the reader is referred to the respective 
subjects elsewhere considered. Cases arising from abnormal states 
of the blood, or nervous system, require chiefly the indicated rem- 
edy, but the great importance of proper hygienic and dietary 
influences must not be overlooked. Frequently the primary cause 
lies in malnutrition brought about by improper food and irregular 
habits of life. Girls that are sedentary in their habits, or are being 
reared under the pernicious influences of an artificial life, are quite 
prone to amenorrhea, and in such we can only hope to secure 
a restoration to health by a systematic and strict observance of 
hygienic rules. The feet should be kept warm and dry ; flannel 
should be worn next the skin at all times ; regular habits should be 
enjoined as to early retiring and early rising, bathing, regular 
meals of plain nourishing food, and regular defecation ; systematic 
exercise, but not to over-fatigue ; plenty of fresh air and sunlight, 
cheerful surroundings and agreeable society. These are important 
measures and should be persistently observed. 

In acute suppression, the hot douche, or hot sitz-or foot-baths, 



AMENORRHEA. 397 

are valuable adjuvants, and indeed they may often prove of equal 
value in chronic cases. 

Electricity may prove servicable in any form of chronic 
amenorrhea. The positive should be applied over the lower por- 
tion of the spine, and the negative over the hypogastrium, or, still 
better, directly to the os uteri. 

The remedies most often called for are as follows: — 

Amenorrhea from chlorosis: — Aletris, Apis, Calcarea carb., 
Arsenicum, Chininum, Chininum ars., Ferrum, Ferrum iod., Fer- 
rum phos., Helonias, Ignatia, Lilium, Nux vom.. Phosphorus, 
Pulsatilla, Sepia, Senecio, Zinc. 

Amenorrhea from plethora: — Aconite, Belladonna, Gelsemium, 
Nux vom., Sulphur. 

Amenorrhea from constitutional diseases : — Aletris, Arsenicum, 
Calcarea carb., Chininum, Chininum ars., Cimicifuga, Conium, 
Ferrum, Ferrum phos., Graphites, Iodine, Phosphorus, Pulsatilla, 
Sepia, Sulphur, Zinc. 

Acute suppression from cold: — Aconite, Belladonna, Pulsa- 
tilla, Causticum, Cimicifuga, Gelsemium. 

Acute suppression from fright or sudden emotions: — Aconite, 
Belladonna, Cimicifuga, Ignatia, Opium. Platinum, Pulsatilla. 

First menses delayed: — Aletris, Calcarea carb., Cimicifuga, 
Graphites, Pulsatilla, Silicea, Sulphur. 

Partial amenorrhea: — Calcarea carb., Cimicifuga, Graphites, 
Phosphorus, Pulsatilla, Senecio, Sepia, Silicea, Sulphur. 

Vicarious menstruation: — Bryonia, Hamamelis, Millefolium, 
Phosphorus, Pulsatilla, Ustilago. 

Only the chief indications for a few of the most important 
remedies can be given. 

Aletris. — From atony of the ovaries and uterus; anremia; 
defective nutrition; indigestion; constipation; fainting; especially 
when weak from protracted illness. 

Apis. — Chlorosis; face cedematous, puffy, waxy; stinging 
pains especially in right ovary; menses scanty and irregular. 

Calcarea Carb. — Especially useful in scrofulous or tuber- 
culous subjects; fair, plump girls, of a leuco-phlegmatic tempera- 
ment; mal-nutrition ; disturbances of indigestion; weary, languid, 
want of vitality; anaemia. 

Cimicifuga. — In rheumatic, neuralgic, choreic or hysterical 
subjects; menses irregular, delayed or suppressed; ovarian irrita- 
tion; uterine cramps; bearing down in uterine region and small of 
back, limbs heavy and torpid; suppression from cold or emotions; 
more generally useful in all classes of amenorrhea than any other 
remedy. 

Ferrum. — In weakh T , chlorotic persons, with fiery redness of 



398 A TEXT-BOOK OF GYNECOLOGY. 

the face; great nervousness and debility; emaciation; rush of blood 
to the head, veins of head swollen; flushes of heat in face. 

Graphites. — First menses delayed, or disturbances at the 
menopause. " Graphites is in climax what Pulsatilla is in youth " 
(Lilienthal). Menses late, scanty and pale; pain in epigastrium as if 
everything would be torn to pieces; patient inclined to obesity; 
induration of ovaries. 

Helonias. — From atony; anaemia; chlorosis; disordered diges- 
tion; general weariness and languor; depressed mood; censorious 
fault-finding; prolapsus from muscular atony; loss of sexual desire. 

Ignatia. — Menses suppressed from grief or suppressed mental 
suffering; frequent sighing; brooding over her troubles; sensation 
of weakness and sinking at pit of stomach; hysteria. 

Lilium Tigr. — Partial amenorrhea accompanied by nervous 
affection of the heart and ovarian irritation or uterine displace- 
ments and leucorrhea. 

Phosphorus. — Amenorrhea with blood spitting, or hemor- 
rhage from the nose, anus or urethra; especially in tall, slender 
phthisical patients; dry cough and tight feeling in the chest. 

Pulsatilla. — Anaemia without chlorosis. First menses de- 
layed; menses late, scanty, and of short duration; suppressed from 
getting the feet wet; heavy pressive pain in abdomen and small of 
.back, as from a stone; leucorrhea like cream or milk; pains shift 
from part to part; constant chilliness; especially adapted to 
patients with light hair and blue eyes, and who are of a gentle, sub- 
missive, tearful disposition. 

Senecio. — Menses suppressed from cold; irregular, tardy or 
scanty; great debility; nervousness; sleeplessness; gastric derange- 
ments; pulmonary disease. 

Sepia. — Menses late and scanty; leucorrhea before the menses, 
like milk, excoriating; uterine displacement; face sallow, with 
yellow spots; bearing-down pains; weakness and tired pain in 
small of back. 



CHAPTER LI. 



MENORRHAGIA. 



DeftjsItion. — Menorrhagia is a too profuse and too protracted 
menstruation — an excessive discharge of blood occurring at the 
menstrual period; when not coincident in point of time with the 
menstrual period, it is known as metrorrhagia. The pathology 
and treatment are the same, so there need be no practical distinc- 
tion between the two. 

Pathology. — It must be borne in mind that a flow of blood 
from the uterus is usually a physiological process, and also that 
the menstrual discharge is naturally more profuse in some than in 
others. Therefore the first point to decide is whether or not the 
discharge is excessive. This is sometimes difficult, as in practice 
we meet every form and degree of change from the normal indi- 
vidual type. In many cases the state of the general health informs 
us at once that the discharge is excessive, but this is not always 
the case. As menorrhagia is itself but a symptom of either func- 
tional or organic disease of the uterus, it follows that its pathology 
is that which characterizes the disease which produces it. How- 
ever, it must be admitted that a violent menorrhagia may occur 
without any disease or pathological state being recognizable, the 
whole difficulty being simply a derangement of function. 

Etiology. — The causes may be classified as constitutional 
and local. 

Constitutional causes. — Delicate constitution; diseases result- 
ing from mal-nutrition, especially Bright's disease; tuberculosis; 
ansemia; purpura; scorbutic conditions; hemorrhagic diathesis; 
excessive lactation; plethora; mental disturbances; cardiac, hepatic 
or other visceral disease. 

Local causes. — Endometritis ; metritis ; subinvolution ; dis- 
placements; inversion; submucous and interstitial fibroids; polypi: 
fungus growths of the endometrium; carcinoma; sarcoma; retained 
products of conception; lacerated cervix; congestion occurring in 
ovaries, Fallopian tubes, or pelvic connective tissue or pelvic 
peritoneum. 

We also should consider such predisposing influences as lux- 
urious living; sedentary or unhealthy occupations; over-work or 
over-study; inordinate sexual indulgence; malaria; climate, resi- 
dents in tropical countries being especially liable. 



400 A TEXT-BOOK OF GYNECOLOGY. 

Menorrhagia may also occur as a sequel to fevers and inflam- 
mations, especially exanthemata. 

Vakieties. — Menorrhagia may be either (1) functional, (2) 
sympathetic or (3) organic. 

1. Functional. — This variety is due solely to functional 
disturbances, there being simply an increase in the quantity of the 
discharge or the frequency of its occurrence, or both. It most 
often arises from plethora, but on the contrary is not infrequently 
the result of such causes as tend to produce debility and constitu- 
tional disease. 

2. Sympathetic. — By this term is understood those cases 
that occur in the course of severe forms of general disease, such 
as Bright's disease, tuberculosis, cardiac or hepatic disease. In 
such cases menorrhagia is often a critical symptom, frequently 
serving to exhaust the feeble forces and hasten a fatal termination, 
on the same principle as a hemorrhage of the nose or bowels. 

3. Organic. — This term "includes those cases that occur in 
connection with and are caused by organic disease of the uterus or 
its appendages, from simple congestion to fibroid and carcinoma- 
tous tumors." 

Symptoms. — The subjective symptoms are dependent entirely 
upon the character of the local or constitutional disease that induces 
the hemorrhage. The discharge itself may vary considerably in 
different cases without regard to the primary disease. Sometimes, 
from month to month, it becomes gradually increased in quantity, 
until there is considerable hemorrhage at each nisus. Again, the 
profuse discharge may commence at once, and much blood be lost 
at each period, and be accompanied by severe pain and the dis- 
charge of clots. This may be the case and at the same time a 
copious hemorrhage occur during the inter-menstrual interval — 
metrorrhagia. Or, the discharge may at no time be very excessive, 
but it is continuous, sometimes alternating with lcucorrhea; this 
constitutes a variety of metrorrhagia. Or, the case may be one of 
pure metrorrhagia, the loss of blood occurring suddenly, and not 
at the menstrual period, and be accompanied by pains in the back, 
hypogastrium, etc. 

The character of the discharge also varies, as do the concomi- 
tant symptoms. Sometimes the latter become serious, arising 
from loss of blood, or because the discharge is only a manifesta- 
tion of some grave disease; bat such cases are too numerous to 
allow of any detailed description. 

Diagnosis. — It is easy enough to diagnosticate menorrhagia, 
but it sometimes becomes extremely difficult to establish the nature 
of the disease which is causing it. In every case where the cause 
is not plainly evident the uterus should be carefully explored, and 



MENORRHA GIA . 401 

its appendages systematically examined, in order that any abnormal 
conditions of these parts may be brought to light. The methods 
for so doing are considered elsewhere. 

Prognosis. -^In functional menorrhagia the prognosis is favor- 
able. In the organic and sympathetic varieties it depends entirely 
upon our ability to discover and remove the cause. 

Treatment. — During an attack the patient should be kept at 
rest in a recumbent posture, the foot of the bed being elevated a 
few inches. None but cold acidulated drinks should be permitted, 
and cold applications, especially ice-bags, applied over the hypo- 
gastrium, while at the same time ice-cold injections may be thrown 
into the vagina, or small pieces of ice applied to the mouth of the 
uterus. While this method is probably the quickest to check a 
violent hemorrhage, yet I am convinced that in most cases the 
persistent use of hot water injections affords the safest and most 
permanent means for controlling the hemorrhage. It' has also 
been recommended to apply strong ligatures to the extremities. 
All other means failing, the vagina should be filled with a tampon, 
for which purpose I use surgeons' sponges, but in an emergency 
it may be necessary to use any available material, cotton wadding, 
or table napkins, which may, if desired, be saturated in a strong 
solution of alum. The cervix may be tamponed by sponge or 
slippery-elm tents. In desperate cases where none of these methods 
prove successful Dr. Thomas recommends that "the cavity of the 
body of the uterus be freely injected, after dilatation of the cervical 
canal, with the tincture of iodine, or solution of persulphate of 
iron, one third to two of water." 

In all cases of menorrhagia, no matter how violent the hemor- 
rhage may be, the homeopathic physician will not forget that he 
has at his command remedies which, if indicated, will often control 
like magic the most desperate attack even without the aid of those 
auxiliary measures already considered, although it is never wise 
to reject any mechanical means that may assist in accomplishing 
the greatly to be desired object. 

The remedies most often used during an attack are Ipecac, 
Belladonna, Aconite, Trillium, Erigeron, Sabina, Cinnamomum, 
Hamamelis, Ferrum, Sulphuric acid. 

Not less important are the means which must be adopted to 
accomplish a radical cure. These depend largely upon the cause, 
which it must be our endeavor to remove. Local conditions must 
be treated according to the means described under their respective 
headings, polypi or tumors removed, fungous growths curetted, 
displacements restored, etc. Constitutional defects must be com- 
bated by the indicated remedy and such hygienic measures as the 
nature of the case suggests. If the blood be impoverished, atten- 



402 A TEXT-BOOK OF GYNECOLOGY. 

tion must be paid to the patient's habits of life. She should have 
nourishing food, plenty of fresh air and sunlight, and moderate 
exercise. A sea-voyage is often of great benefit, and frequently a 
change from a warm to a cold climate or from the lowlands to a 
mountainous region will in itself accomplish a cure. Especially 
in cases of malarial or tuberculous origin is a change of climate 
desirable. Daily cokl hip-baths are of great value, or a sponge- 
bath, the skin being thoroughly rubbed with a crash towel. Rest 
in the recumbent posture should be secured for two or three days 
before the period, and sexual intercourse be prohibited during that 
time. The remedies liable to be called for in constitutional condi- 
tions are too numerous to mention in detail. They are chiefly 
Arsenicum, Calcarea carb., Chininum, Chininum ars., Ferrum, 
Ferrum phos., Mercurius, Nitric acid, Nux vom., Silicea, Sulphur, 
Zinc. 

I will mention the chief indications for a few of the remedies 
most frequently used in menorrhagia. 

Belladonna. — Especially from plethora. Discharge profuse, 
bright red and feels hot to the parts; flushed face, throbbing 
carotids; hard, full and bounding pulse; blood sometimes dark- 
red, decomposed and offensive; pressure, uneasiness and weight 
in uterine region, as if contents of abdomen would protrude through 
the vulva. 

Calcarea Carb. — Chronic cases arising from constitutional 
diseases, scrofula, tuberculosis, etc., especially in women of a 
leuco-phlegmatic temperament. Feet feel cold and damp; chilly 
and sensitive to slightest draught of air; also during lactation or 
at the menopause. 

Caulophyllum. — Passive hemorrhage from atony of the ute- 
rus; especially after abortion or confinement. 

Chamomilla. — Discharge of clotted blood, which is dark red 
or black and fetid, accompanied by severe labor-like pains; flow 
intermittent and irregular; sensitive to pain; peevish and irritable; 
attacks of faintness. 

Chininum. — From atony of the uterus; ringing in ears, faint- 
ing, cold, loss of sight, blood dark and clotted; uterine spasms; 
twitches, jerks; wants to be fanned; especially in those who have 
lost much blood. 

Cinnamomum. — Very profuse flow of bright red blood. Dr. 
Winterburn says: (1) "It has always done well in my hands, and 
has several times stopped severe hemorrhages after other appar- 
ently well-selected remedies had failed to make an impression." 

Crocus Sat. — Menorrhagia of dark, stringy, tenacious blood, 
coming away in long black strings; sensation of something alive 

1) Arndt's System of Medicine, p. 393. 



MENORRHAGIA. 403 

in the abdomen. Dr. Winterburn says he has never been able to 
verify the last symptom, which is according to my own experience. 
He especially recommends Crocus in functional monorrhagia occur- 
ring in young unmarried women. 

Cyclamen. — Blood black and clotted; dizziness, stupefaction, 
and obscuration of vision, as if a fog were before the eyes. 

Erigeron Can. — Profuse and alarming hemorrhage of bright 
red blood; every movement of the patient increases the flow; pallor 
and weakness in consequence of the discharge; frequent and urgent 
desire to urinate and spasmodic pelvic pains. 

Ferrum. — Hemorrhage from the uterus, with labor-like pains 
in abdomen, and glowing heat in the face; blood light or lumpy, 
coagulates easily; Aoav generally delayed and frequentry intermit- 
tent; comes on for a day or two, then ceases for some hours, 
returns, again ceases, but returns, and so on. Women who, 
though weak and nervous, have a very red face; in delicate chlo- 
rotic women. 

Hamamelis. — Active hemorrhage; blood bright red, or, pas- 
sive flow of venous blood; no uterine pains. According to Winter- 
burn this remedy is useful in those passive hemorrhages, without 
much pain, in patients who suffer from varicoses, and who belong- 
to the class of easy bleeders. 

Helonias. — Atonic and passive menorrhagia; very profuse 
flow at every period, so that her strength is exhausted, and she 
suffers from debility; sallow and pale complexion; menorrhagia 
from ulcerated os or cervix, the blood being dark and bad smelling 
and continuing a long while; the flow is increased by the least 
exertion. 

Ipecacuanha. — Blood bright red, profuse, clotted; nausea, 
breathing heavy, oppressed; stitches from navel to uterus. This 
remedy is more often used than any other in uterine hemorrhages, 
but is seldom useful unless there is constant nausea, Winterburn 
says: (1) "If the hemorrhage is very severe, audit seems desirable 
to stop it at once, I give Ipecacuanha, unless some other remedy 
is characteristically indicated." 

Millefolium. — Hemorrhage of bright red and fluid blood; 
uterine hemorrhages after great exertion ; with congestive headache. 

Nitric Acid. — This remedy is not often used in menorrhagia. 
but Dr. Lucllam recommends it highly in cases of supervening abor- 
tion or during the menopause where there is a passive, irregular 
flow, and other remedies have failed. There is a loss of appetite, 
headache, malaise, and a series of symptoms that are chargeable 
to the continual drain upon her physical resources. She cannot 
sit upright or stand erect but the difficulty is increased. 

1) Op. Cit., p. 391. 



404 A TEXT-BOOK OF GYNECOLOGY. 

Nux Vomica. — Especially suitable to women of irascible tem- 
perament ; fiery and easily excited, and to those who suffer from 
mental over-exertion, sedentary habits, excess of coffee-drinking 
or stimulants, or from too much rich food; flow dark, thick and 
coagulated ; preceded by contractive uterine spasms. 

Platinum. — Flow dark and clotted, with much bearing down 
and drawing pains in abdomen ; sensation as if she were growing 
larger, and feels that everything about her is small and inferior ; 
hysteria ; great sexual excitement, but shrinks from an embrace 
because the organs are so painfully sensitive ; organic monor- 
rhagia, accompanying carcinoma, fibroids, etc. 

Sabina. — This is one of our most frequently used remedies in 
uterine hemorrhages ; the flow occurs in paroxysms ; worse from 
motion ; blood dark and clotted, sometimes offensive. The chief 
characteristic is a drawing pain from the back through to the 
pubis. I once cured the most desperate case of menorrhagia that 
ever came within my knowledge, of over twenty years' standing, 
with this drug, my attention being called to it by the fact that the 
patient could not endure the sound of music. Dr. Winterburn 
says (1): "The pathological condition calling for Sabina is hyper- 
emia of the uterus ; and the nearer this approaches the inflamma- 
tory stage, the more likely is this remedy to be of service." This 
is true, yet, nevertheless, Sabina will often cure long standing 
cases resulting from atony, and, on the other hand, also menor- 
rhagia from plethora. Lilienthal says "plethoric women with 
habitual menorrhagia." In some respects the remedy is similar to 
Belladonna, but the symptoms will readily differentiate. 

Secale Cor. — Discharge black, fluid and very fetid ; worse 
from the slightest motion ; strong, spasmodic, expulsive pains in 
the uterus ; especially in feeble, cachectic, dyscratic women. 

Trillium. — Active or passive hemorrhage ; gushing of bright 
red blood at least movement ; later blood pale, from anaemia ; 
sometimes blood dark, thick and clotted ; pain in back and cold 
limbs ; flow returns every two weeks ; at menopause ; after exhaus- 
tion from exercise. 

Ustilago Maidis. — From atony of the uterus ; blood dark 
and clotted ; aching distress in uterus ; slow and persistent oozing 
of dark blood, with small black coagula ; the finger upon being 
withdrawn from the vagina is covered with dark semi-fluid (but not 
watery) blood, as though partial disorganization had taken place ; 
uterus enlarged, cervix tumefied, os dilated, swollen, and flabby ; 
perfect inertia of the uterus (Lilienthal). 

Zincum. — Dr. Winterburn says of this remedy (2): "It has 

1) Op. Cit., p. 392. 

2) Op. Cit., p. 394. 



MENORRHAGIA. 405 

this singular characteristic, that although the flow is abnormal in 
frequency and quantity, she feels perfectly well as soon as it sets in 
and as long as it continues. Before menstruation she is in constant 
pain in the small of her back, especially about the last lumbar 
vertebra; worse when sitting, better when walking, and relieved by 
pressure. Her restlessness is peculiar. She cannot keep her feet 
still, and she suffers from a variety of hysteric complaints. These 
conditions all return after menstruation, and with them an irresist- 
ible sexual desire, caused by vulvar pruritus. Zincum vies with 
Hamamelis in the varicose diathesis. Varices on the genitals, legs, 
and elsewhere are the source of the eroticism and of much of her 
pain ; hence the relief from a free catamenial discharge. Zincum 
cures the varicosis and restores the functional operations of the 
womb to pristine rectitude." 



CHAPTER LIL 



DYSMENORRHEA. 



Definition. — Dysmenorrhea is a painful menstruation, the 
pain usually occurring just before or during the flow, but it may 
also be present after the flow has ceased. 

Pathology. — Dysmenorrhea being but a symptom of various 
pathological states, it cannot be said to have any pathology which 
is distinctively its own. If all the organs of generation and their 
surrounding tissues are in perfect form and vigor, and sustain 
their normal relations to one another, and at the same time the blood 
and nervous systems are unimpaired, menstruation will take place 
without creating distinct pain, it being accompanied by only a sense 
of fullness and discomfort in the parts, and slight bearing-clown 
sensations in the back and loins. As to its severity, dysmenor- 
rhea may vary in degree from this normal condition, to one in 
which the patient suffers for a few hours or for many days the most 
excruciating and agonizing pains, which gradually undermine the 
health, and may induce other complications which together 
eventually destroy life. This condition may be brought about by 
any pathological state which causes a change in the shape or posi- 
tion of the uterus, congestion of the uterus, ovaries or surround- 
ing cellular or serous tissues ; or, a depreciated condition of the 
blood and nervous system creating a tendency to neuralgia, the 
uterine nerves, as a consequence, being in a state of hyperesthe- 
sia. If neither of these conditions are present, dysmenorrhea is 
not likely to occur, though our knowledge of pathology is not yet 
so perfect that we can say that such a thing would be impossible. 

Varieties. — For study and clinical convenience we may clas- 
sify dysmenorrhea as follows : — (1) Congestive ; (2) Neuralgic ; 
(3) Membranous ; (4) Obstructive. Some authors include also the 
spasmodic and ovarian varieties, but, as a rule, cases included in 
the former belong rather to the obstructive variety, while those 
dependent, supposedly at least, upon ovarian disturbance, may 
properly be classified as either congestive or neuralgic. It must 
be remembered, however, that any classification is more or less 
arbitrary, and cannot be rigidly followed. Nature does not always 
follow the lines thus established, to say nothing of those cases 
which present the characteristics of more than one variety, being 
dependent upon more than one pathological condition. 

406 



CONGESTIVE DYSMENORRHEA. 407 

1. Congestive Dysmenorrhea. 

At the menstrual period, as has already been noted, a certain 
amount of congestion is normal, which involves the mucous 
lining of the uterus and tubes, sometimes also including the ovaries, 
the cellular tissue and the peritoneum. Whenever from any cause 
this normal congestion increases beyond physiological limits, the 
condition is known as congestive dysmenorrhea. 

Etiology. — As may be readily inferred, but slight causes are 
sometimes necessary to induce an aggravation of the already exist- 
ing normal congestion. These are most apt to operate in full- 
blooded, plethoric girls, who sometimes suffer more or less from this 
form of dysmenorrhea through life, the least exciting cause serving 
to intensify their sufferings. Yet at the same time congestive 
dysmenorrhea may occur in weak and anaemic girls who are sub- 
ject to any of the following causes : — General plethora ; sedentary 
or luxurious mode of life ; exposure to cold or wet ; displacements ; 
fibroid tumors ; chronic metritis ; endometritis ; salpingitis ; ovari- 
tis ; pelvic cellulitis ; pelvic peritonitis. 

Symptoms. — The patient usually complains for a few days 
before the period of a feeling of fullness, weight and heat in the 
back and pelvis, the flow being ushered in with more or less violent 
symptoms of a congestive or inflammatory nature, flushed face, 
hot skin and increased temperature. The pain varies in severity 
and character, but it is usually a steady, dull pelvic pain. The 
hypogastrium is usually more or less distended, hot and sensitive to 
the touch, the latter being often more noticeable over the left ova- 
rian region. If the flow comes on freely the patient is ordinarily 
relieved, but this is not always the case, the suffering sometimes 
continuing to a greater or lesser extent for several days. 

Prognosis. — As a rule the prognosis is favorable, though 
cases resulting from irremediable pathological states are sometimes 
found. There are cases, too, occurring usually in plethoric women, 
where more or less aggravation of the normal menstrual congestion 
seems to become a habit of the individual, and relief comes only 
with the menopause. 

Treatment. — Ordinarily this form of dysmenorrhea is amen- 
able to the indicated remedy, both as to t palliation and cure. As 
to the former, hot fomentations or the hot-water bag may afford 
great relief, but opiates should never be employed. If the dys- 
menorrhea be due to displacement, or structural disease, including 
any chronic pelvic inflammation, this condition must be treated 
according to the rules considered elsewhere in this book. In such 
cases dysmenorrhea is only one of the many symptoms that result 
from the pathological state, whatever it may be, and the symptom 



408 A TEXT-BOOK OF GYNECOLOGY. 

itself cannot be overcome without first removing the diseased con- 
dition which causes it. 

The remedies most often required are, Aconite, Apis, Bella- 
donna, Bryonia, Cimicifuga, Ferrum phos., Lachesis, Nux vom., 
or Viburnum op. 

2. Neuralgic Dysmenorrhea. 

In this class there is usually no structural lesion or organic 
disorder, the dysmenorrhea depending upon the presence of a 
neurotic constitution, the nervous system in general and the uterine 
nerves in particular, being in a state of morbid sensibility, so that 
the causes which might in others produce neuralgia of the head or 
stomach or other parts, here concentrate their force upon the 
uterine nerves, giving rise to hyperesthesia, which, under the 
influence of the menstrual congestion, causes pain. As one author 
says, ' ' the nerves play a part corresponding to that of the vessels 
in the congestive form." 

Etiology. — The predisposing causes are in general the same 
as those wdiich tend to produce neuralgia in other parts: — The 
neuralgic diathesis, either hereditary or acquired; hysteria, which 
is rather a result of the nervous condition, than a cause; chlorosis; 
plethora; malaria; gouty or rheumatic diathesis; mental depres- 
sion; luxurious and enervating habits; onanism; excessive sexual 
indulgence, or ungratified sexual desire; ovaralgia. 

Symptoms. — In this variety of dysmenorrhea the patient 
seldom at any time experiences an entire freedom from suffering. 
During the inter-menstrual period she may feel only a sensation of 
weakness, weariness and weight, but oftener she suffers more or 
less with headache, neuralgia and other nervous affections, includ- 
ing hysteria, which become more pronounced as she approaches 
the menstrual nisus. At this time also she may show aberrations 
of temper, irritability and a tendency to melancholy. In some 
cases there is no considerable inconvenience until the menstrual 
period arrives, which is usually quite regular. At this time, 
whether prodromata have been present or not, the patient expe- 
riences excruciating pain in the uterine region, back and loins, 
which usually moderates or entirely disappears when the flow is 
established, but in some cases continues with more or less severity 
during the whole period. The neuralgic nature of the pain is 
recognized not only by its character, but also by the fact that in 
some women it occurs at some distant part of the body, as the eye 
or face, instead of the uterine region, while in others it may alter- 
nate in its location, or involve different localities at the same time. 
The feet and hands are almost invariably cold. After the attack 
she is usually greatly exhausted for several days. 



NEURALGIC DYSMENORRHEA. 409 

Diagnosis. — The presence of the above described symptoms, 
and the absence of anatomical changes, are usually sufficient to 
establish the diagnosis. The pains are not expulsive, the blood is 
not clotted, and physical examination reveals no obstruction. 
From the congestive form it is chiefly differentiated by the absence 
of congestive symptoms. It is also, when once established, more 
regular in its occurrence, regardless of exciting causes. 

Prognosis. — As in other neuralgias the prognosis depends 
largely upon our ability to discover and remove the cause. If the 
patient inherit a neuralgic diathesis, the prospects for a cure are 
very discouraging. Otherwise, if she will consent to the adoption 
of such hygienic measures as are required to restore the tone of 
the nervous system, the prognosis is quite favorable. 

Treatment. — The first duty of the physician is to prescribe 
such hygienic, measures as will have a tendency to restore the tone 
of the nervous system. The patient should, if possible, be relieved 
of all mental worry and excitement, and not be exposed to the in- 
fluences of cold or damp, though in pleasant weather an abundance 
of fresh air and sunlight are indispensable. Flannels of proper 
weight should be worn next the skin during all seasons. She 
should take regular and systematic exercise, though never carry- 
ing it to the point of fatigue. A plain, nourishing diet is essen- 
tial, and all the habits of life, especially as to sleeping, eating and 
defecation, should be regular. Often a change of climate and 
scenery will afford much benefit. 

Electricity has proved a valuable adjuvant in the treatment of 
this disease. It should be used two or three times a week during 
the inter-menstrual interval, and applied as a general tonic as well 
as locally, according to the usual seat of the pain. For the former 
purposes I usually have the patient place her feet in warm water 
in which has been placed the positive pole, treating the upper part 
of the body, down to the thighs, with the negative pole. I always 
use the Faradic current, though Drs. Hammond, Anstie and other 
distinguished neurologists, always use the galvanic. Such patients 
are quite apt to be sterile, but, if conception can be brought about, 
parturition will often effect a cure. 

When the symptoms commence the patient should take a hot 
foot-bath and go to bed, where she should be kept quiet and warm, 
using hot applications to the abdomen and extremities if necessary. 
If the bowels are constipated she should previously use a copious 
enema of castile soap-suds. 

In cases in which the suffering is extreme, the temptation to 
give an opiate is very great, but, we should remember that such 
relief is only temporary — often no more than can be had with the 
properly indicated homeopathic remedy, that it is obtained at the 



410 



A TEXT-BOOK OF GYNECOLOGY. 



expense of the patient's general health, and, being oft repeated, is 
almost sure to lead her to acquire the morphine habit. 

The remedies most often required are : — Asclepias, Bella- 
donna, Caulophyllum, Chamomilla, Cimicifuga, Gelsemium, Hyos- 
cyamus, Ignatia, Phosphorus, Platinum, Pulsatilla, Viburnum, 
Xanthoxylum. For indications see end of chapter. 

3. Membranous Dysmenorrhea. 

Definition. — Membranous dysmenorrhea is painful men- 
struation accompanied by the discharge of larger or smaller pieces, 
tube-shaped portions, or pear-shaped sacs forming complete casts 
of the lining membrane of the uterus. 

Pathology and Etiology. — It must be understood at the 
outset, that the membrane cast off in this form of dysmenorrhea is 
not a plastic exudation due to a croupy or diphtheritic endome- 
tritis, as was once supposed, but, that it consists of more or less 
of the lining membrane of the uterus. Various theories have been 




Fig. 193. — Sketch of a dysmenorrheal membrane as seen under water. 

advanced to account for this process, but none of them have been 
fully established. Dr. Williams, of London, contends, as do 
many others, that "the whole, or a large amount of the mucous 
lining of the body of the uterus is cast off at every period. In 
health this is accompanied by a fine disintegration, giving rise to 
no pain or visible phenomena. Under certain as yet obscure con- 



MEMBRANOUS DYSMENORRHEA. 



411 



ditions, however, disintegration of the mucous coat does not take 
place, though expulsion does." 

Dr. Oldham claims ' 4 that at some time during the inter- 
menstrual period, the entire lining membrane of the uterus is lifted 
from its base and separated, so as to be ready for extrusion at one 
of the next menstrual crises.'- How this is accomplished, and, 




Fig. 194. — A dysmenorrhea! membrane laid open. 

why it occurs in only a small number of women and not in others, 
is still unknown, but it is generally supposed to result from in- 
flammation or congestion. Scanzoni attributes it to " a consider- 
able hyperemia of the wall of the uterus, which is followed by 
an excess in the development of the mucous membrane." Simpson 
attributes it ' ' to an exaggeration of a normal condition, or to an 
exalted degree of a plrysiological action." It has also been claimed 
that the membrane was deciduous in its character, the product of 
an abnormal conception, but as it occurs in women who have 
never had sexual intercourse, this theory has been discarded. 
Winckel, wdio is one of our most recent and reliable authorities, 
says that, "the membrane shows the changes characteristic of 
endometritis; therefore, the term endometritis dissecans, is not in- 
appropriate." Dr. Winterburn says that, "it should be noted 
that the membrane thus thrown off is not the product of the pre- 
sent catamenial epoch, but of the preceding one." 

Winckel thus describes the anatomical appearance of the mem- 
brane: (1) " These membranes show a smooth reddish inner sur- 



1) Op. Cit.. p. 488. 



412 A TEXT-BOOK OF GYNECOLOGY. 

face upon which the orifice of the utricular glands may be seen by 
the naked eye, and an external rough uneven surface, which 
appears as though torn from its connections, and it occasionally 
contains small blood clots. It is of unequal thickness, is usually 
very thin and almost transparent at the points where the walls join 
each other, and somewhat thicker at those portions where the 
mucous membrane has not been uniformly exfoliated. In many 
cases the discharged membrane is a complete sac containing three 
openings corresponding to the os uteri and the orifices of the tubes. 
Sometimes this exfoliative endometritis is associated with an ex- 
foliative colpitis; large pieces of membrane, consisting of nucleated 
pavement epithelium, are discharged, and these are followed by 
tenacious fibrinous portions like those thrown off after the applica- 
tion of a concentrated solution of alum; yet, I have seen such a 
colpitis dissecans occur in a virgin who had not used injections." 

The microscope shows an excess of round small cells and 
fibrillated tissues, the former being easily differentiated from the 
large irregular cells of a decidual membrane. 

Symptoms. — The symptoms vary much in intensity in differ- 
ent individuals, in some the membrane being discharged regularly 
with but little pain. Ordinarily the period is introduced by slight 
pains which gradually increase in intensity, until they become vio- 
lent and expulsive, like the pains of abortion, and cease only when 
the membrane has been expelled, which is usually on the second or 
third, or more rarely, on the fourth day. The flow is not always 
profuse, being sometimes quite scanty, and not infrequently the 
membrane plugs up the cervix so that the blood is retained, and is 
discharged in clots after the expulsion of the membrane. The 
time between the periods is usually free from pain, but the patient 
usually feels weak and miserable, and may complain of various 
symptoms which are the result of existing complications. 

Diagnosis. — The nature of the pains and their regularity with 
each menstrual period, together with the character of the mem- 
brane expelled, are usually sufficient for diagnosis, but it may be 
necessary to submit the latter to a microscopical examination in 
order to differentiate either from an early abortion, or, less often, 
blood-casts or fibrinous moulds of the uterus, or exfoliations of the 
vaginal mucous membrane, or the exudations of diphtheritic 
endometritis. 

Prognosis. — This is usually considered unfavorable, though if 
treatment be commenced at an early stage a cure may be effected. 
The disease is not dangerous to life, though it may become asso- 
ciated with complications that are sometimes fatal. Sterility is a usual 
consequence of membranous dysmenorrhea, but cases are reported 
where conception has occurred in advanced stages of the disease. 



OBSTRUCTIVE DYSMENORRHEA. 413 

Treatment. — The hygienic measures already suggested for 
neuralgic dysmenorrhea should, to some extent at least, be applied 
in this variety. From our present knowledge of the pathology of 
this disease it is impossible to deny that some dyscrasia is at its 
foundation, which may be partially overcome by a proper atten- 
tion to the diet and habits of the patient. By some it is claimed 
that the disease occurs only in persons of a rheumatic diathesis, 
and if so, it is especially necessary that the patient be protected 
from atmospheric changes. She should wear flannel next the 
skin continually, and so far as possible enjoy the benefits of a 
mild, dry and even climate. 

Relief is sometimes obtained by having the patient anticipate 
the period a few hours by going to bed and applying heat to the 
abdomen, sacrum and extremities. 

Various methods of treatment, such as dilatation of the uter- 
ine cavity, discission of the cervical canal, cauterization of the 
uterine mucous membrane, curetting the uterus, scarifying the 
mucous membrane, and the application of leeches have been re- 
sorted to by old-school authorities with negative results. Dilata- 
tion of the cervix with tents often affords relief. On this point 
Dr. Ludlam says (1): "Very decided benefit may sometimes be 
derived from the employment of the sponge tent, with a view to 
dilate and remove any obstruction of the cervix which prevents 
the free escape of the menstrual blood. This would cause the 
womb to disgorge, unload its capillaries, relieve the hyperemia, 
avert an excessive hypertrophy of the mucous membrane, and 
possibly prevent its exfoliation. Moreover — and it is by no means 
an inconsiderable thing — this dilatation greatly mitigates the suf- 
ferings of the patient." 

The remedies most often used are: — Borax, Bromine, Bryonia, 
Calcarea carb., Cantharis, Caulophyllum, Iodium, Rhus tox., Col- 
chicum, Collinsonia, Kali iod., Phosphorus, Gelsemium, Secale, 
Ustilago. For the nervous and other concomitant symptoms that 
may arise, many other remedies may be indicated. See indica- 
tions at the end of this chapter. 

4. Obstructive Dysmenorrhea. 

Definition. — A variety of dysmenorrhea dependent upon a 
partial or complete closure or obstruction of the genital canal, 
causing an impediment to the free escape of the menstrual dis- 
charge which collects above the obstruction and is only expelled 
by violent spasmodic pain. The obstruction most often exists in 
the cervical canal or at the os, but it may be in the vagina or at 
the vulva. 



1) Op. Git, p. 233. 



414 A TEXT-BOOK OF GYNECOLOGY., 

Etiology. — The causes of obstructive dysmenorrhea are: — 
Atresia of the cervix or vagina, congenital or acquired; atresia of 
the hymen; stenosis of the cervix, congenital or acquired; flexion 
or version of the uterus, the former creating an angle in the canal, 
the latter less often causing obstruction by firm pressure of the os 
against the vaginal wall; fibroid tumors in the cervix, causing dis- 
tortion of the canal; uterine polypus obstructing the cavity or neck, 
often acting as a ball valve at the os internum, preventing the 
egress of fluids, but allowing the passage of a probe. 

Symptoms. — No symptoms are manifest until a sufficient 
amount of blood has accumulated within the uterus to cause dis- 
tension, when spasmodic contractive pains are excited for the 
purpose of overcoming the obstruction. The pains gradually become 
more and more severe, the expulsive efforts resembling those of 
abortion, though more painful. Finally a discharge of more or 
less blood results and the pains are relieved until the accumulation 
has again taken place, when the process is repeated. The flow 
sometimes comes drop by drop, but more often the uterine con- 
tractions are followed by gushes, the blood being frequently clotted, 
the clots sometimes corresponding in size and shape to that of the 
uterine cavity. 

In many cases, especially if they have existed for a length of 
time, more or less reflex symptoms are present. Vomiting is quite a 
common symptom, which is often obstinate and painful in character. 
There may also be indigestion, rectal and vesical tenesmus, and 
nervous disorders, such as insomnia, chorea, hysteria, cramps, and 
even convulsions. 

Diagnosis. — Ordinarily the character of the pain and the reg- 
ularity of its occurrence at each menstrual period will establish 
the nature of the case, but a positive diagnosis rests alone on a 
physical examination. The presence of an obstruction must be 
demonstrated beyond a doubt. This is accomplished chiefly 
by the touch and the sound, though a bi-manual or rectal examina- 
tion, or even the speculum, may be necessary. 

Prognosis. — This depends chiefly upon our ability to over- 
come the mechanical obstruction. In some cases, however, the 
general state of the health resulting from persistent menstrual 
derangement is such that the prospects for an ultimate radical cure 
are less hopeful. 

Treatment. — The administration of remedies which accom- 
plish so much in other varieties of dysmenorrhea, is of little use 
here. The obstruction which gives rise to the trouble being 
purely mechanical in its nature, the treatment is necessarily sur- 
gical in character, though the pain may sometimes be temporarily 
relieved, or the constitutional or concomitant symptoms ameliorated 



THERAPEUTICS OF DYSMENORRHEA. 415 

by the use of the indicated remedy, or, by proper hygienic measures. 
In some instances the patient finds by experience that she obtains 
some relief by assuming and maintaining a certain position. This 
usually occurs when the trouble arises either from flexion or uterine 
distortion from a fibroid tumor. 

The surgical treatment of the various conditions which give 
rise to obstructive dysmenorrhea are fully considered elsewhere 
in this work under their respective heads, to which the reader is 
referred. 

Therapeutics of Dysmenorrhea. 

Aconite. — Congestive dysmenorrhea; high fever; abdomen 
swollen, hot and sensitive to the touch; vomiting; great restless- 
ness and anxiety; pelvic inflammations. 

Ammonium Carb. — Cholera-like symptoms at the commence- 
ment of the menses; blood black and clotted; acrid; making the 
thighs sore; especially in nervous delicate women. 

Ammonium Mur. — Discharge of a quantity of blood from the 
bowels at every catamenial period; during the flow the discharge 
at night is more profuse. 

Apis. — Congestive or neuralgic dysmenorrhea from ovarian 
influences; enlargement of the right ovary, which is sensitive and 
painful; also with pain in the left pectoral region, with cough; 
sharp plunging or stabbing pains in the uterus, or in the head, 
sometimes followed by convulsions, at every menstrual period, the 
patient feeling tolerably well during the interval; scanty, dark 
urine; waxy skin. 

Asclepias Cor. — Dysmenorrhea associated with dropsy; or 
catarrhal conditions; intermittent, bearing-down, labor-like pains. 

Belladonna. — Congestive dysmenorrhea in plethoric women, 
especially girls, or, when associated with local pelvic inflammations; 
rush of blood to the head; throbbing headache; full bounding 
pulse; abdomen hot, painfully distended and sensitive to the touch 
or jarring; great pressing downward in the genitals, as if they 
would protrude through the vulva. 

Borax. — Membranous Dysmenorrhea. — Menses too early, 
too profuse, and attended with colic and nausea. 

Bromium. — Membranous dysmenorrhea ; violent contractive 
spasms during the menses, lasting for hours, leaving the abdomen 
sore ; loud emissions of flatus from the vagina. 

Bryonia. — Membranous dysmenorrhea, or, when associated 
with rheumatic symptoms ; distension of the abdomen, and colic ; 
profuse flow ; stitching pains, worse from the slightest motion. 

Cactus. — Excruciating, agonizing pain in the lumbar region 
during the menses, sensation of painful constriction in the groins, 



416 A TEXT-BOOK OF GYNECOLOGY. 

extending around the pelvis ; flow scanty, ceasing when lying 
down ; acute pains and sensations of constriction about the heart. 

Cantharis. — Membranous dysmenorrhea ; burning in the 
vulva and ovarian region; itching in the vagina; vesical tenesmus 
and painful urination. 

Caulophyllum. — Congestive or neuralgic varieties ; also ob- 
structive from retroflexion or retroversion; spasmodic pains in the 
uterus and various portions of the hypogastric region; congestion 
and irritability of the uterus; fullness, heaviness and tension in the 
hypogastric region; scanty flow. 

Chamomilla. — Drawing from the sacral region forward; 
griping, pinching, or labor-like pains in the uterus, followed by dis- 
charge of large clots of blood; tearing pains in the legs; very 
sensitive to pain; nervous and irritable. 

Cimicifuga. — All things considered, this is our most valuable 
remedy in all varieties of dysmenorrhea. It is especially useful in 
congestive or neuralgic forms, when occurring in nervous, hyster- 
ical or rheumatic women; lancinating shooting pains in the uterine 
and ovarian regions; bearing-down in the uterine region and small 
of the back; excruciating pains in the abdomen, small of the back 
and limbs; nervous headache; hysterical spasms; scanty flow; 
between the periods debility, nervous erethism, neuralgic pains. 

Cocculus. — Neuralgic dysmenorrhea in nervous, hysterical 
women; cramps in the abdomen; colic pains; faintness and debility; 
nausea; convulsions. 

Collinsonia. — Obstructiye or other forms of dysmenorrhea 
resulting from hemorrhoids or constipation; pruritus; displace- 
ments. 

Gelsemitjm. — Neuralgic, congestive, and what has been 
termed by some authors, spasmodic dysmenorrhea; severe, sharp, 
labor-like pains in the uterine region, extending to the back and 
hips, dull aching in the lumbar and sacral regions; neuralgia of 
distant parts; cramps in the abdomen and legs; convulsions. 

Hyoscyamus. — Extreme nervousness, even to mania, or hys- 
terical spasms ; during the menses convulsive trembling of the 
hands and feet; headache, nausea and profuse sweat; labor-like pains 
in the uterus, with pulling in the loins and small of the back; in- 
voluntary loud laughter and silly actions ; lascivious, uncovers and 
exposes herself. 

Ignatia. — In nervous, hysterical women who sigh and brood 
over imaginary troubles ; violent labor-like pains, followed by dis- 
charge of black clotted blood of a putrid odor. 

Kali Brom. — Very nervous, restless and sleepless; neuralgic 
form from ovarian or uterine irritation ; obstructive form from sub- 
involution or fibroids. 



THERAPEUTICS OF DYSMENORRHEA. 417 

Kali Carb. — Cutting, stitching pains in the abdomen ; aching 
in the small of the back ; uterine spasm ; menses acrid, of a bad 
odor, excoriating the thighs; especially useful after loss of fluids or 
vitality, especially in anaemic persons. 

Kali Iod. — When occurring in mercurial, syphilitic or 
scrofulous subjects, or when associated with or arising from 
chronic rheumatism; frequent urging to urinate when the menses 
appear; tearing, darting pains in the limbs; painful bloating of the 
abdomen; subsultus tendinum; always worse at night. 

Lachesis. — Labor-like pains and sharp pains in the left ova- 
rian region and in the uterus, relieved when the flow begins ; the 
uterus will not bear the contact even of the bedclothes, which cause 
uneasiness, but not pain. 

Lilium Tig. — Neuralgic dysmenorrhea, or dysmenorrhea from 
displacement; bearing-down, with sensation of heavy weight and 
pressure in the uterine region, as if the whole contents of the pel- 
vis would press out through the vagina; severe neuralgic pains in 
the uterus and ovaries ; sub-acute uterine inflammation ; sympa- 
thetic cardiac symptoms. 

Nux Vomica. — Contractive uterine spasms; colic pains fol- 
lowed by the discharge of coagula ; pressure toward the genitals ; 
pain in the back ; nausea ; faintness ; constipation ; irritable, over- 
sensitive, choleric patients. 

Platina. — Painful sensitiveness and constant pressure in the 
region of the mons veneris and genital organs, Avith internal chills 
and external coldness, except of the face ; bearing-down and draw- 
ing pains in the abdomen; spasms and screaming; flow dark and 
clotted; ovarian inflammation; pruritus; nymphomania; hysteria. 

Pulsatilla. — Heavy pressive pain in the abdomen and small 
of the back, as from a stone; the limbs tend to go to sleep; men- 
strual colic; flow thick and black; chilliness; symptoms ever chang- 
ing; shifting pains; nausea, especially mornings; the patient 
peevish, fretful and inclined to weep. 

Secale. — The discharge black, fluid, very fetid; expulsive 
pains; colic; spasms; cold extremities; cold sweat; weak pulse 
and great prostration. 

Senecio. — Dysmenorrhea with urinary sufferings, tenesmus, 
heat and urging; pain in the back and loins; pale, weak, nervous, 
sleepless, hysterical; catarrhal subjects. 

Sepia. — Dysmenorrhea from endometritis; weakness and 
tired pain in the small of the back; bearing-down and pressure in 
the uterine region; leucorrhea before the menses, yellow, like 
milk; excoriating; like pus; of bad smelling fluids; displacements. 

Sulphur. — Long standing and obstinate cases in scrofulous 
subjects; headache before the menses; headache and nosebleed 



418 A TEXT-BOOK OF GYNECOLOGY. 

during the menses; blood thick, dark, acrid, corroding, sour-smell- 
ing; yellowish, corrosive leucorrhea; burning in the vagina. 

Thuja. — The congestive form, from ovarian inflammation; 
distressing burning pain when moving; she must lie down; much 
noisy flatus in the abdomen; vaginismus. 

Ustilago Maidis. — Membranous dysmenorrhea; the blood 
dark and clotted; constant aching distress in the uterus; burning 
in the ovaries. 

Veratrum Alb. — Dysmenorrhea, with vomiting and purging, 
or exhausting diarrhea and cold sweat; nymphomania before the 
menses. 

Veratrum Viride. — The congestive variety; menstrual colic ; 
intense cerebral congestion; strangury before the menses; con- 
vulsions. 

Viburnum Opulus. — This is one of our most promising 
remedies for dysmenorrhea; it relieves all cases of the congestive 
or neuralgic type, and sometimes membranous and obstructive 
also, but its action seems to be exhausted in about three months. 
Before the menses, severe breaking-down, drawing in the anterior 
muscles of the thighs; heavy aching in the sacral region and over 
the pubes; occasional sharp, shooting pains in the ovaries; pains 
make her so nervous she cannot sit still; excruciating, cramping, 
colicky pains in the lower abdomen and through the womb; pains 
begin in the back and go around, ending in cramps in the uterus. 
During the menses, nausea; cramping pain and great nervous 
restlessness; the flow ceases for several hours, then returns in clots; 
the flow scanty, thin, light-colored, with sensation of lightness of 
the head; faint when trying to sit up. 

Xanthoxylum. — Neuralgic dysmenorrhea, especially in 
women of a spare habit and of a delicate, nervous temperament; 
ovarian pains extending down the genito-crural nerves. Dreadful 
distress and pain; headache; menses too early and too profuse; 
pains down the anterior part of the thighs. 



CHAPTER LIII. 



LEUCORRHEA. 



Synonyms. — Fluor albus; Blennorrhea; Whites. 

Definition. — The term leucorrhea is used to designate any 
discharge from the genital canal other than blood. 

Leucorrhea is but a symptom of an irritation or inflammatory 
disease of the genital tract, and as such has been referred to in 
previous chapters; yet, as a matter of clinical convenience, it will 
be considered separately from the morbid conditions which pro- 
duce it. 

Varieties. — Leucorrhea may be distinguished both anatom- 
ically and clinically as (1) vulvar, (2) vaginal, (3) cervical, and (4) 
uterine. 

1. Vulvar leucorrhea occurs chiefly in children, but is also 
present in aged women, especially associated with pruritus. In 
young children in whom the sebaceous glands are not yet developed, 
and in old women after the glands have atrophied, the discharge 
is serous or sero-purulent in character. At puberty and during 
the child-bearing period the sero-purulent discharge becomes mixed 
with the secretions of the vulvo-vaginal and sebaceous glands, 
rendering it viscid and unctuous, having a characteristic cheesy or 
fishy odor. 

2. Vaginal leucorrhea occurs most often in young women, 
and consists of a white, creamy, purulent-looking fluid. 

3. Cervical leucorrhea is most frequent during the child- 
bearing period. It is thick, tenacious and ropy, having the appear- 
ance of the unboiled white of an egg. 

4. Uterine leucorrhea occurs mostly during the child-bearing 
period and resembles cervical leucorrhea, but is more watery and 
less dense and gelatinous in character, and is more often tinged 
with blood, or yellowish in color from the admixture of pus. 
Sometimes after the menopause a uterine leucorrhea occurs 
which consists simply of a thin, watery, unirritating fluid. 

While these varieties are usually very readily distinguished 
for diagnostic purposes, yet not unfrequently do we find more 
than one variety present in the same patient, and it becomes 
necessary to examine the discharges microscopically to ascertain 
their respective character and proportions. 

Pathology. — In a state of health there is poured out from 

419 



420 A TEXT-BOOK OF GYNECOLOGY. 

the glands and mucous lining of the genital canal, from the orifice of 
the vagina to the termination of the Fallopian tubes, a secretion suf- 
ficient to lubricate the opposed surfaces of the mucous membrane. 
This may at times become physiologically increased, as before or 
after menstruation, during sexual intercourse, or during parturition. 

So, also, women suffer from a temporarily increased discharge, 
the result of causes which produce temporary congestion of the 
mucous membrane, such as cold, fatigue or exhaustion, but the 
effect, with the cause, soon passes away, and can scarcely be 
considered as pathological; but when the increase takes place from 
abnormal stimuli, and constitutes a permanent fluid discharge 
from the genitals, it is pathological, and is known as leucorrhea. 
This is essentially a catarrh, and, as a nasal or bronchial catarrh 
may result from a moderate degree of vascular excitement or 
inflammation of their respective mucous surfaces, so does leucorrhea 
signify a similar condition of the mucous lining of the genital 
tract. But, as in other catarrhs, its presence is not invariably an 
evidence of inflammatory action, but may result from congestive 
disturbances which do not fully approach an inflammatory state. 
It is not unusual to find leucorrhea associated with catarrhal condi- 
tions of other parts, especially in persons of a scrofulous habit, all 
the mucous tracts of the body being apparently involved in the 
catarrhal disturbance. In other cases leucorrhea will alternate 
with catarrhal discharges from other parts, becoming aggravated 
as soon as such discharges cease, whether the cessation be due, as 
in some instances, to local medication, or to other causes. Fritsch 
claims that vaginal leucorrhea cannot be a catarrh ' ' because the 
so-called mucosa is no mucous membrane, but an epidermis, and 
contains no organs secreting mucus." Nevertheless, the existence 
of a vaginal mucus is too well established to be successfully con- 
tradicted, and indeed, recent pathology recognizes a catarrh of the 
epidermis — eczema. 

The characteristics of the leucorrheal discharge vary accord- 
ing to the location from which it is secreted, not only in its general 
appearance, as has already been noted under the previous heading, 
but also in its microscopical and chemical analysis. 

Vulvar leucorrhea is chiefly sebaceous in character, and is 
nearly always mixed with vaginal mucus. 

Vaginal leucorrhea has an acid reaction and shows under the 
microscope, according to Dr. Tyler Smith, the following elements:— 
plasma; scaly epithelium ; pus-corpuscles; blood-globules and fatty 
matter. 

Cervical and uterine leucorrhea has an alkaline reaction, and 
shows under the microscope: — plasma; mucous corpuscles; altered 
cylindrical epithelium; pus-corpuscles; blood-globules and fatty 
matter. 



LEUCORRHEA. 421 

According to Dr. Barnes we may summarily describe the 
distinguishing characters of these varieties as follows: — vulvar, 
sebaceous; vaginal, epithelial; uterine, mucous. 

Wherever a breach of surface has taken place from ulceration 
or other causes, pus may be found in proportion to the extent of 
the lesion. 

Etiology. — Any causes which produce pelvic congestion also 
tend to produce an exaggeration of the normal mucous secretion of 
the genital canal. Often these cases are of a comparatively trifling 
nature. This is evident from the great frequency of the disease, 
which has been known since the earliest times, having been men- 
tioned by Hippocrates and other ancient writers, and which consti- 
tutes the most common disorder of the female generative organs, 
few women having been entirely exempt from it, though in many 
instances the cause is so trifling and the departure from the physio- 
logical so slight, that the condition can hardly be said to constitute 
either a disease or a symptom. 

Causes may be distinguished as predisposing and exciting. 
The predisposing causes are those belonging to some constitutional 
diathesis, being either strumous, tuberculosus, syphilitic, gouty or 
rheumatic, and also the blood states of anaemia or chlorosis. 

Exciting causes may be distinguished as congestive or non- 
inflammatory, and inflammatory. 

Congestive or non-inflammatory causes: — Sub-involution; la- 
cerated cervix; deranged menstruation; foreign growths, fibroids, 
polypi, etc.; prolonged laceration; congestion and parturition; 
abortion; excessive sexual indulgence; uterine displacements; 
traumatic influences; pessaries; efforts to prevent conception, cold 
water injections, etc.; irritating injections. 

Inflammatory causes: — Endometritis, cervical or corporeal, 
invariably causes leucorrhea; vaginitis, simple or specific; syphilitic 
ulcerations; foreign growths, fibroids, polypi; all inflammatory 
conditions of the uterus and its appendages. 

In both categories may be included exposure to cold, which 
may result in simple congestion, or give rise to true inflammation. 
When we remember that leucorrhea is essentially a catarrh, analo- 
gous to that occurring in the nose and elsewhere, we may readily 
understand why cold, which is the chief etiological factor of catarrh 
of any mucous surface, may also be a frequent cause of leucorrhea. 

The leucorrhea of children, either vulvar or vaginal, results 
from either the migration of worms from the rectum, from un- 
cleanliness, from exposure to cold by sitting on damp ground or 
cold objects, such as stone steps, etc., or from masturbation. 

Symptoms. — The subjective symptoms are mostly those which 
result directly from the existing causes rather than from the dis- 



422 A TEXT-BOOK OF GYNECOLOGY. 

charge itself, though instances undoubtedly arise where irritating 
and long-continued leucorrheal discharges give rise to symptoms 
which are of the same nature as those which result from any long- 
lasting discharge or debilitating influence. The most constant 
symptom of leucorrhea is a pain in the back and loins, which is 
always worse from active exercise, such as walking or riding. 
These symptoms are always more intense in uterine leucorrhea, and 
are more apt to be associated with symptoms of an inflammatory 
character, than when resulting from vaginal leucorrhea. Uterine 
leucorrhea is more related to the menstrual functions, being 
usually aggravated immediately before and after the flow. The 
excoriations liable to arise from an excessively acrid discharge are 
also symptomatic. 

Diagnosis. — It is quite easy to diagnose the presence of 
leucorrhea, but it is more difficult to ascertain its nature and dis- 
cover the cause which produces it. Frequently, in order to accom- 
plish this, it is necessary to test the chemical reaction of the 
discharge by means of litmus paper, and also to examine with the 
microscope to ascertain the character of its distinctive elements. 
(See pathology.) If the secretions of the uterus and vagina 
become mixed so that an examination is difficult, the method rec- 
ommended by Schultze for diagnosticating between uterine and 
vaginal catarrh may be adopted. The vagina is douched out in the 
evening, and a tampon soaked in a solution of tannin is placed 
against the os externum ; in the morning the tampon is removed 
through the speculum, and we note the quantity and character of 
the discharge which has accumulated upon it. Ordinarily the 
history of the case and the physical appearances of the discharge 
are sufficient for diagnostic purposes, so far as the leucorrhea is con- 
cerned, but in most instances a thorough knowledge of the pathol- 
ogy of the case can only be ascertained by a careful physical 
exploration. 

Prognosis. — This is usually favorable, but depends entirely 
upon our ability to discover and remove the cause. 

Treatment. — The constitutional or symptomatic treatment of 
leucorrhea is of the greatest importance, though local treatment in 
many cases should not be disregarded. It must be continually 
borne in mind that leucorrhea is itself but a symptom either of 
some constitutional dyscrasia, or of some local exciting cause. In 
the former case the treatment should be exclusively constitutional, 
though simple douches of hot water, or of salt and water, for pur- 
poses of cleanliness and antisepsis, are not to be overlooked. 
Such cases, however, can only be cured by appropriate constitu- 
tional treatment. On the other hand, leucorrhea that results from 
vaginitis, or endometritis, or other local diseases, may require such 



LEUCORRHEA. 423 

local treatment as has already been recommended in those affec- 
tions. As a general prescription for a local medicament in all 
cases regardless of the cause, where for any reason local treatment 
is desirable, there is nothing better than the following : — 

Fluid Hydrastis §i; 
Fluid Calendula fi; 
Glycerine fvi. Mix. 

Sig. One tablespoonful in half a teacup of warm water used as an in- 
jection once a day. 

The same preparation can also be used on a cotton tampon, if 
desirable. In case the discharge is foul-smelling, a few drops of 
Carbolic Acid may be added. 

Daily injections of hot water are often of great value. Tepid 
salt-water is the simplest and one of the most efficient douches for 
ordinary catarrhal leucorrhea. Its value has long since been 
demonstrated in nasal catarrh, and it is equally useful here. 
Hamamelis diluted with tepid water acts well in many cases. 
Astringent washes are not needed, and should not be employed. 
They may check the discharge temporarily, but in the end they are 
productive of harm. 

If the leucorrhea results from displacement or from foreign 
growths within the uterine canal, these must receive the usual treat- 
ment before remedies can be expected to do any good. When a 
constitutional diathesis is present, or the patient has become debil- 
itated, much attention should be paid to the use of such hygienic 
measures as will assist in restoring the vigor and tone of the 
system. A nourishing diet, fresh air and sunshine, gentle exer- 
cise, appropriate bathing, etc., are indispensable. In most cases 
sexual intercourse should be avoided, or indulged in to only a lim- 
ited extent. Almost any remedy in the materia medica may be 
indicated in leucorrhea, together with the pathological states which 
give rise to it. It is therefore important that each individual case 
be carefully studied, and the remedy selected that will nearest 
cover the totality of the symptoms. 

I will give the chief indications for a few of the most impor- 
tant remedies: 

Therapeutics of Leucorrhea (including Vulvitis, Vaginitis, and 

Endometritis). 

Aconite. — Acute simple vaginitis. Vagina dry, hot and sensi- 
tive ; painful urging to urinate ; urine scanty and scalding hot ; 
sometimes retention of urine. 

iEscuLUS. — Thick, dark, corroding leucorrhea, with aching 
and lameness in the back across the sacro-iliac articulations. 

Alumina. — Profuse, transparent, acrid leucorrhea, running 



424 A TEXT-BOOK OF GYNECOLOGY. 

down to the feet during the day; burning in the genital organs; parts 
inflamed and corroded, making walking difficult; relieved by wash- 
ing with cold water. 

Ammonium. — Leucorrhea like white of eggs; Ibrown, slimy, 
unpainful, after urination. 

Arsenicum Alb. — Leucorrhea profuse, yellow, thick, corrod- 
ing. Thin, whitish, offensive discharge, instead of the menses; 
especially in cachectic women; emaciated; weak, even slight effort 
fatigues; burning pains in the pelvis; carcinoma; vulvitis. 

Belladonna. — Acute endometritis; cervix sensitive, swollen 
and red; burning pressure, weight and throbbing pain in the 
uterine region. 

Borax. — Leucorrhea like the white of an egg, with sensation 
as if warm water were flowing down; white, thick as paste; leucor- 
rhea occurring just midway between the menstrual periods. 

Bovista. — Leucorrhea a few days before or a few days after 
the menses, like the white of an egg, when walking; flowing only 
at night. 

Calcarea Carb. — Leucorrhea like milk, with itching and 
burning; inflammation and swelling of the genitals; impaired nutri- 
tion; leuco-phlegmatic temperament; girls who are obese, but not 
muscular; scrofulous or tubercular diathesis. 

Calcarea Phos. — Leucorrhea like the white of an egg; girls 
at or near puberty; strumous diathesis. 

Cantharis. — Acrid, burning leucorrhea; swelling and irrita- 
tion of the vulva; violent itching in the vulva; pruritus with strong 
sexual desire; painful urination. 

Carbo Yeg. — Leucorrhea thin, in morning on arising, not 
through the day; milky; excoriating; red sore places on the pudenda; 
aphthae; itching; sore and raw; varices of the vulva. 

Chamomilla. — Leucorrhea acrid, watery, yellow, smarting; 
patient irritable and cross. 

Cinchona. — Leucorrhea instead of or before the menses, 
with spasmodic uterine contractions; great debility; sensitive to 
pain and to draughts of air; malarial cachexia. 

Cimicifuga. — Said to be especially useful in endocervicitis 
when occurring in nervous, neuralgic or hysterical patients; 
irregular or painful menstruation; uterus and ovaries enlarged 
and sensitive. 

Cocculus. — Leucorrhea in place of the menses, like serum, 
mixed with a purulent ichorous liquid; painful pressure in the 
uterus, with cramps in the chest, nausea and fainting; hysteria. 

Conium. — Leucorrhea, with weakness and paralyzed sensa- 
tion in the small of back, before the discharge; thick, milky, with 
contractive, labor-like pains, coming from both sides; of white 



LEUCORRHEA. 425 

acrid mucus, causing burning; carcinoma; severe itching deep in 
the vagina. 

Erigeron. — Leucorrhea profuse, with spasmodic pains, and 
irritation of the bladder and rectum. 

Ferrum. — Leucorrhea mild, milky or corrosive, causing 
itching, with soreness; great weakness and emaciation; nervous; 
easily fatigued; erethistic chlorosis; weak; very red face. 

Ferrum Iod. — Leucorrhea like boiled starch; when the bowels 
move the discharge is stringy; itching and soreness of vulva and 
vagina; parts much swollen; displacements; scrofulous subjects; 
chlorosis. 

Graphites. — Profuse leucorrhea of very thin white mucus, 
with weakness in the back; discharge occurs in gushes day or 
night; menses too late, scanty and pale. 

Hamamelis. — Leucorrhea with much relaxation of the vaginal 
walls; profuse discharge, constituting a drain on the system as 
severe as a bleeding; passive hemorrhages. 

Helonias. — Leucorrhea associated with general atony and 
anaemia; sensation of soreness and weight in the womb, a " con- 
sciousness of a womb;" deep, undefined depression, and melancholy. 

Hydrastis. — Leucorrhea tenacious, ropy, thick, yellow; 
erosions of the os, cervix, vagina; pruritus vulvae, with profuse 
leucorrhea; sexual excitement. 

Iodium. — Leucorrhea acrid, corroding the limbs; worse at 
time of menses; induration and swelling of the uterus or ovaries. 

Kali Bich. — Leucorrhea yellow, ropy; pain and weakness 
across the small of back, and dull, heavy pains in hypogastrium; 
suitable to fat, light-haired people. 

Kreasotum. — Leucorrhea of a yellow color, staining linen 
yellow, with great weakness; white leucorrhea having the odor of 
green corn; leucorrhea excoriating, causing soreness between the 
pudenda, also between the thighs and pudenda, with burning, itch- 
ing pains; violent itching of the labia, also of the vagina, obliged 
to rub the parts; external genitals swollen, hot, hard, and sore. 

Lachesis. — Green or thick yellow leucorrhea between or just 
before menses; chilly at night, with flashes of heat in daytime; 
congestion of the womb, with prolapsus; great prostration, espe- 
cially when exercising or lifting; tendency to fainting in nervous 
women; cannot bear any pressure, nor even her clothes, upon the 
uterine region; scanty menses, with increased leucorrhea; especially 
suitable for cases at the menopause. 

Lilium Tig. — Leucorrhea bright yellow, acrid, excoriating, 
leaving a brown stain; displacements; ovarian irritation; hysteria; 
sympathetic heart symptoms. 

Lycopodium. — Leucorrhea like milk; bloody; corroding; 



426 A TEXT-BOOK OF GYNECOLOGY. 

sensation of dryness in vagina; burning during and after coition; 
discharge of wind from the vagina. 

Magnesia Mur. — Uterine spasms, followed by leucorrhea; 
leucorrhea after every stool; profuse discharge of a watery, thick 
mucus from the vagina; scirrhous induration of the uterus. 

Mercurius Sol. — Leucorrhea always worse at night; green- 
ish discharge; smarting, corroding, itching, burning after scratch- 
ing; purulent leucorrhea; vaginitis; prolapsus of vagina; cases of 
vulvitis; rawness, smarting and excoriated spots; gonorrheal or 
syphilitic origin. 

Natrum Carb. — Leucorrhea thick, yellow, putrid, ceasing 
after urination. 

Natrum Mur. — Leucorrhea profuse, of a greenish color, 
worse while walking; corrosive itching of genitals; delayed and 
scanty menses, with headache, yellowness of the face; chlorotic, 
cachectic patients, with sallow skin, frequent palpitation, flutter- 
ing of the heart, and oppression of the chest. 

Nitric Acid. — Leucorrhea offensive ; green mucus ; cherry 
colored ; flesh colored; excrescences on cervix uteri; itching on the 
pudenda; syphilitic ulcers in the vagina and on os uteri, burning 
and itching. 

Nux Moschata. — Leucorrhea in place of menses; flatulent 
distension of the uterus; hysteria; fainting, with palpitation of the 
heart, followed by sleep. 

Phosphorus. — Acrid, excoriating leucorrhea; amenorrhea 
with chlorosis; leucorrhea from onanism; scanty menses; carcinoma; 
suitable for tall, slender women of a tubercular habit. 

Phosphoric Acid. — Profuse yellow leucorrhea, mostly after 
menses; meteoristic distension of the uterus; leucorrhea from debil- 
itating influences or onanism; in young girls who are growing too 
fast. 

Phytolacca. — Uterine leucorrhea, proceeding from the glan- 
dular portion of the cervix; ulceration of the os uteri; scirrhus and 
cancer. 

Platina. — Leucorrhea like albumen, only in the daytime, 
without sensation, particularly after micturation, or after rising 
from a seat; painful pressing toward the genital organs, as if the 
menses would make their appearance; voluptuous tingling in the 
pudenda and abdomen, with oppressive anxiety and palpitation of 
the heart; induration of the uterus; cramp and stitches in the indu- 
rated womb; scirrhus of the uterus; hysteria, with great depres- 
sion of spirits and melancholia from uterine disease. 

Podophyllum. — Leucorrhea of thick, transparent mucus ; 
prolapsus uteri, with aching and bearing-down pains ; sensation as 
if genitals would come out during stool. 

Pulsatilla. — Leucorrhea thick, like cream or milk, with swol- 



LEUCORRHEA. 427 

len vulva; painless; acrid, thin, burning; first menses delayed; 
or menses suppressed, with abdominal cramps ; pain in small of 
back; sandy hair, blue eyes, pale face, inclined to silent grief and 
submissiveness. 

Rhus Tox. — Erysipelatous inflammation of the external gen- 
itals; eczema of the vulva, vesicles and crusts, with burning and 
itching; soreness and pain in the vagina. 

Sabina. — Leucorrhea thick, yellow, fetid, after suppressed 
menses; suitable to plethoric women with profuse menstruation. 

Sanguinaria. — Leucorrhea fetid, corrosive, at and after the 
menopause; flushes of heat; ulcerations and erosions of os uteri. 

Senecio. — Leucorrhea instead of the menses, or with urinary 
troubles; deranged menstruation. 

Sepia.— Leucorrhea yellow, like milk, excoriating, like pus; 
of bad-smelling fluids; before the menses; great dryness of vulva 
and vagina; painful to touch; coition very painful; prolapsus uteri; 
sensation as if everything would come out of the vagina, has to 
cross her limbs to prevent it; pain in back and small of back; pain- 
ful sensation of emptiness in stomach and abdomen; face pale or 
yellowish; especially suited to women with dark hair, and particu- 
larly during pregnancy, child-bed, and while nursing; our most 
valuable remedy in chronic cases. 

Silicea. — Profuse, acrid, corrosive leucorrhea; pressing-down 
feeling in vagina; itching, burning, and soreness in the vulva; 
increased menses with repeated paroxysms of icy-coldness over the 
whole body; want of vital heat, even when taking exercise. 

Stillingla. — Copious muco-purulent leucorrhea, with rheu- 
matic pains, in syphilitic or rheumatic patients. 

Sulphur. — Profuse yellowish, corrosive leucorrhea; burning 
in the vagina, is scarcely able to keep still; papular eruptions on gen- 
itals; pruritus; obstinate chronic cases, especially in scrofulous 
subjects. 

Sulphuric Acid. — Leucorrhea acrid or burning, or like 
milk; discharge of bloody mucus from the vagina, as if the menses 
would set in. 

Thuja. — Profuse mucus discharge; sycotic excrescences, 
moist, bleeding and offensive; biting and itching in the genitals. 

Trillium. — Profuse, exhausting, yellowish leucorrhea with 
atony, prolapsus, and chronic engorgement of the cervix; fetid 
discharges from uterus and vagina. 

Viburnum. — Leucorrhea thin, yellow-white, or colorless, 
except with the stool, when it is thick, white, blood-streaked; dys- 
menorrhea. 

Zixcum. — Leucorrhea of thick mucus; bloody mucus; excor- 
iating after the menses; pruritus vulvae; nervous and anaemic; great 
exhaustion; nervous, fidgety moving of the feet. 



CHAPTER LIV. 



CHLOROSIS. 



Synonyms. — Chloro-ansemia; Spanaemia ; Green-sickness; 
Cachexia virginum. 

Definition. — A special form of anaemia, peculiar to the 
female sex, and usually occurring in connection with disordered 
menstrual function, or with the evolution of the reproductive or- 
gans at puberty. 

Etiology. — The causes of chlorosis are predisposing, or 
constitutional and exciting. Age and sex are the most important 
predisposing causes, the disease almost invariably occurring in the 
female sex, and especially during the period of puberty. Cases 
of chlorosis in the male are extremely rare, and in women the 
disease very seldom occurs any length of time either before or 
after puberty. The lymphatic temperament and scrofulous dia- 
thesis are also considered as predisposing causes. Some authors 
hold that chlorosis is a neurosis of the sympathetic nervous system, 
and that its development is due largely to nervous causes, some of 
which may have been congenital. Other authors claim, that the 
disease is due to congenital malformations of the heart and blood- 
vessels. I am inclined to the opinion, however, that the disease 
is more often acquired than inherited. It occurs frequently in 
over-worked young girls in large cities, who are confined most of 
the time in poorly lighted and badly ventilated apartments, and 
whose food is deficient in both quantity and quality. On the 
other hand, the remarkable frequency of chlorosis in the higher 
classes is due to a lack of proper exercise, especially in the open 
air, a stimulating rather than a healthy, nourishing diet, irregular 
habits, and the influence upon the mind of pernicious literature, 
and not infrequently the habit of masturbation. So, also, do emo- 
tional causes play an important part; jealousy, disappointed love, 
grief, prolonged mental anxiety, ungratified sexual desire and 
home-sickness may excite the disease, or at least favor its develop- 
ment, as may also continued loss of sleep, and excessive mental 
application. 

Symptoms. — These are to a great extent the same as those of 
anaemia. The most striking symptom is the pale, greenish, almost 
transparent hue of the skin — a yellowish green tinge, which has 
given to the disease its popular designation of green-sickness. 

428 



CHLOROSIS. 429 

Sometimes in blondes the skin is of a transparent white, while in 
the brunettes it is more of a dirty-gray or yellowish color. This 
symptom arises from a deficiency of the red corpuscles. There 
are occasional instances where the cheeks retain their redness, 
which is explained on the grounds of the distension of the capil- 
laries with blood. The transient flush observed in almost all 
chlorotic persons when excited or heated arises from the same 
cause. 

Subcutaneous fat is present in normal amount, which is not 
the case in anaemia associated with phthisis and other constitu- 
tional diseases. The patient is subject to difficulty of breathing, 
or want of breath, palpitation and fainting upon any unusual, 
even though moderate, exertion. The appetite and taste are im- 
paired. Ordinary diet is rejected with loathing, and the patient 
craves acid fruits, pickles, vinegar, etc., or earthy substances, 
such as chalk, coal and slate-pencils. 

The menstrual functions are always deranged, either a per- 
sistent amenorrhea or a watery discharge taking the place of the 
menstrual discharge, or the latter is scanty and occurs at irregular 
intervals. Some chlorotic subjects, especially girls of nervous 
excitable temperament, have menorrhagia. According to Virchow, 
amenorrhea is present when there is a retarded or imperfect deve- 
lopment of the uterus and ovaries, and excessive menstruation 
when there is hyperplasia of these organs. 

In those cases in which the deficiency of red globules is 
marked, a blowing sound, which extends along the arterial trunks 
of the neck, is heard at the base of the heart. " Where this defi- 
ciency is extreme there is commonly heard in the jugular veins 
that peculiar and characteristic noise known as the hruit-de-diable, 
or the German 'Nonnengerausch.' This sound gives not only 
precise diagnostic indication of the malady, but its intenshry affords 
accurate estimate of its progress. In proportion as the quality of 
the blood improves under treatment the noise diminishes. It 
appears to be directly associated with the relative absence of the 
red globules. When these are present in due proportion the sound 
is no longer heard. " (1) 

In proportion to the extent of the anaemia murmur do we 
usually find vertigo, syncope, and sparks and spots before the 
eyes. Neuralgia, both central and peripheral, is nearly always 
present. Of the peripheral variety, prosopalgia is most frequent, 
and of the central, cardialgia. Sometimes hysterical symptoms 
are manifest, and the usual contradictory mental phenomena of 
that disease are present, mental depression usually predominating. 
The urine is pale and of low specific gravity, due to deficiency in 

1) Barnes 1 Diseases of Women, p. 164. 



430 A TEXT-BOOK OF GYNECOLOGY. 

coloring matter and urea. The whole system is disturbed, and 
symptoms of deranged function are liable to cccur in any organ. 

The condition of mind is quite similar to that arising from 
onanism. The patient dislikes society, avoids the male sex, and 
is shy and backward to a very noticeable extent. 

Pathology. — The pathology of chlorosis has not been defi- 
nitely ascertained. While it is altogether probable that the real 
fons et origo of chlorosis is in the sympathetic nervous system, 
nevertheless the pathological changes which have so far been dis- 
covered lie mainly in the blood, which, as Virchow says, may be 
regarded as a tissue consisting of cells with a liquid intercellular 
substance called serum. 

These changes differ only in degree from those found in 
anaemia. Indeed, many authors do not treat of chloro-anaemia 
as a distinct condition, but consider these two disorders identical 
as to their pathology. Several French pathologists have of late 
years advanced the view that chlorosis differs from anaemia mainly 
in that the latter is merely a blood state, while the former is a 
disease of the nervous system, which may or may not produce this 
blood state. 

The serum of the blood does not, according to Niemeyer, (1) 
"present any constant anomaly. Its composition is generally 
normal; more rarely there is a diminution of its albumin. In 
other cases, again, the amount of albumen of the blood-serum 
seems to be increased, so that, besides the oligocythaemia, there 
is hyperalbuminosis. In the first two instances, the whole 
volume of the blood is probably reduced, while in the latter the 
possibility cannot be denied that, in spite of the diminished number 
of the blood-corpuscles, the absolute bulk of the blood is augmented, 
adding a serous plethora to the oligocythaemia. 

' ' In pronounced chlorosis, the disease in the red blood corpus- 
cles may be so great that a thousand parts of blood cells may con- 
tain but sixty or forty parts of dried blood cells, instead of the 
normal average of one hundred and thirty parts. 

' ' Upon the autopsy of a chlorotic person, who has died of 
intercurrent disease, the viscera are all found to be remarkably pale. 
In some cases, the signs of simple fatty degeneration are found in 
the tunica intima of the great vessels." 

Diagnosis. — Chlorosis may be complicated by hysteria, hypo- 
chondriasis, hypertrophy of the heart and tuberculosis. It is some- 
times difficult to positively exclude one or the other of these diseases 
in forming a diagnosis. It may also be difficult to differentiate 
from other forms of cardiac disease; tubercular peritonitis, and 
especially from pure anaemia. 

1) Practical Medicine, Vol. II, p. 803. 



CHLOROSIS. 431 

From all these organic lesions a diagnosis cannot at once be 
positively established, but by repeated physical examinations and 
careful watching we can, after a time, arrive at the truth. Some- 
times chlorosis gradually develops a tuberculosis, and the physician 
should be constantly on the alert for such a change. 

The history of the case will usually aid in deciding between 
chlorosis and anaemia, the latter always being secondary to wast- 
ing diseases, hemorrhages or mal-nutrition. In hysteria the scle- 
rotica is dull and humid, very different from the transparent hue 
found in chlorosis. 

Prognosis. — The course of the disease is usually slow, but 
unless serious complications exist the prognosis is good, though 
relapses very often occur. Chlorosis itself never endangers life, 
but it favors the development of other diseases which may prove 
fatal. 

Treatment. — First of all should be considered the hygienic 
treatment of chlorosis, without which, in most cases, remedies will 
prove of little avail. 

Cheerful and congenial society and surroundings; plenty of 
open air and sunlight; moderate and well regulated exercise, con- 
sisting of out-door games, walking, driving, playing ten-pins, 
tennis or croquet; sea-bathing; change of scenery, especially from 
city to country; all these are of the utmost importance. The food 
should be taken at regular intervals, and consist of an extremely 
nutritious diet, such as meat, game, fish, oysters, milk, eggs, etc. 

When menstrual derangement is a prominent feature, hot 
baths, especially sitz-baths, should be employed daily. Electricity, 
too, is a valuable adjunct in the treatment of the disease. 

I will give the indications for a few of the most important 
remedies in chlorosis. 

Ferrum. — Iron is unquestionably homeopathic to chlorosis, 
and is, all things considered, our most valuable remedy. It is not 
to be used, however, without discrimination, as it has been by the 
old school for the past half century, and longer. The beneficial 
effects of iron in chlorosis and anaemia are not due, as is assumed 
by allopathic authorities, to the fact that it is supplied as a food to 
the blood, which is deficient in this constituent, for the lack of 
iron in the system is due to a failure in assimilation, and no mat- 
ter how much iron is introduced, only a small quantity is assimi- 
lated and appropriated by the hungry tissues, the balance being 
eliminated by the intestines. 

The only fair assumption possible is that iron owes its thera- 
peutic virtues to the same essential dynamic agency possessed by 
other drugs, and its application is subject to the same therapeutic 
law. It should, then, never be employed except when thoroughly 



432 A TEXT-BOOK OF GYNECOLOGY. 

indicated, otherwise it will do more harm than good. It is 
especially useful in delicate, nervous girls who have a very red 
face, and who flush easily and have epistaxis. Anorexia; vomit- 
ing; watery diarrhea; menses suppressed or watery; leucorrhea; 
weakness and consecutive disease of the heart; general weakness 
and emaciation; oedema; constant chilliness and evening fever, light 
hectic fever. Iron and Strychnia are strongly recommended by Dr. 
W. H. Holcombe, of New Orleans, and Dr. Ludlam, of Chicago. 

Calcare a Carbonicum. — Very useful. Leuco-phlegmatic tem- 
perament; scrofula; disposition to cold and diarrhea; great weak- 
ness or curvature of the spine; vertigo ongoing up stairs; disgust 
for meat; craving for sour and indigestible things; after eating 
swelling of the stomach and palpitation of the heart; menses too 
often, too profuse, or wanting; leucorrhea; great shortness of 
breath; great muscular debility; walking wearies and makes the 
heart palpitate; sitting causes backache and headache, therefore 
constant inclination to lie down; hands and feet cold and damp; the 
fingers appear dead. Imaginary fears about the state of her health. 

Cinchona. — Malarial complications; after loss of fluids; great 
exhaustion; oedematous swellings; poor digestion; distension of 
abdomen; eructations; ringing in the ears; over-sensitiveness of 
nervous system; erythism. 

Pulsatilla. — Weakness and sluggishness in the circulation; 
soft and irregular pulse, and palpitation of the heart"; mal-assimila- 
tion, with signs of anaemia, such as dizziness when rising; 
amenorrhea, or scanty, slimy menses, which appear too late; patient 
feels better in the open air. 

Helonias. — An excellent remedy when Iron seems to be the 
remedy but does not agree. Profound debility, as after severe 
acute diseases; amenorrhea marked by general atony ; prolapsus uteri 
from want of muscular tonicity ; loss of sexual desire and power, 
with or without sterility; mind exceedingly dull and inactive. 

Sepia. — Patient pale, delicate, sensitive to cold air; mental 
depression and indifference; prolapsus uteri; bearing-down in pel- 
vis; leucorrhea; pain in back; amenorrhea. 

Ignatia. — Sensitive, nervous, and hysteric women, inclined to 
spasmodic and intermittent complaints, and where the trouble is 
induced by mental emotions, such as fright, grief, disappointed love. 

Aletris. — Anaemic debility of chlorotic girls and pregnant 
women, suffering from slow digestion and flatulence; scanty, pale 
menses, or amenorrhea. 

Nux Vomica. — Hypochondriasis; dyspepsia; constipation; 
menorrhagia. 

Also consult Arsenicum, Ferrum iod., Ferrum, Gelsemium, 
Phosphorus, Phosphorus ac, Platinum, Zincum. 



CHAPTER LV. 



HYSTERIA. 



Definition. — A peculiar and indefinable neurosis, dependent, 
in a great majority of cases, upon an irritation of the generative 
organs. 

Etiology. — As has already been indicated hysteria is usually, 
possibly always, dependent upon some irritation of the genital 
organs, and is almost invariably intimately associated with some 
disorder of the menstrual functions. Fritsch says: — "Neither the 
occurrence of hysteria in children nor in old women speak against 
this view. In children it would have to be placed parallel to pre- 
cocious menstruation; in old women we should be justified in 
assuming that through the prolonged abnormal nervous activity 
the functions of the peripheral nerves, as well as those of the 
central organs, have become pathological. The fact that hysteria 
has been found with perfectly normal genital organs has no weight 
nowadays; for in extirpated ovaries absolutely nothing was found 
that could be interpreted as pathological, although the gravest 
"hysterical" symptoms had completely disappeared after cas- 
tration. 

"The irritation leading to the reflex neurosis, to hysteria, is 
usually justly relegated to the ovary; for hysteria has been found 
with defect of the uterus. To be sure, in hysteria a number of 
symptoms are observed which are identical with certain subjective 
symptoms of pregnancy. In the same way, we have stated before 
that indications, at least, of hysteria. occur almost invariably with 
dislocation of the uterus and with chronic perimetritis. But this 
furnishes no proof that the irritated uterus is likewise to blame for 
the hysteria, for during pregnancy changes occur in the ovaries 
which are also found in the circulatory disturbances and disloca- 
tions of the uterus." (1) 

Upon this point Dr. Emmett says: "Hysteria is supposed by 
many to be caused directly by ovarian irritation, but, while grant- 
ing that hysteria and ovarian disorders generally coexist, I am not 
disposed to admit a necessary relation between them of cause and 
effect. Ovarian irritation, or defective action of the ovaries, and 
the different nervous manifestations all spring from defective action 
in the nerve centers, the result of faulty nutrition. 

1} Diseases of Women, by Henry Fritsch, M.D., Win. Wood & Co.. p. 388. 

433 



434 A TEXT-BOOK OF GYNECOLOGY. 

' ' After a shock or morbid impression has been once made on 
nerve centers, it requires but a slight exciting cause to bring on, 
at any time, these nervous manifestations. Hysteria, therefore, 
may be associated with any or all of the uterine or ovarian disturb- 
ances having, as we have seen, the same cause, viz., defective 
nerve forces; and any local lesion or disorder may, by reacting on 
a susceptible nervous system, excite, at any time, the nervous 
manifestations." (1) 

Guernsey holds that hysteria bears the same relation to the 
nerves of the reproductive system as chlorosis does to those of 
nutrition, and that it has no exclusive connection with the uterus 
or other particular organs, more than chlorosis has with the stomach 
or other organs of digestion. 

Notwithstanding this statement, however, Dr. Guernsey soon 
follows by saying that ' k the ovaries, as the center of the sexual 
system, must now be regarded as the real fons et origo of a majority 
of cases of hysterical affections." 

This theory of the origin of hysteria is not only borne out by 
the fact that in most instances pressure upon one or the other 
ovary will usually cause an aggravation of the hysterical manifes- 
tations, but also by the fact that cases have been observed in the 
male sex, simulating hysteria, which were always accompanied 
by symptoms of tenderness and irritation of the testicles. I have at 
the present time a case of this nature under treatment, a man thirty 
years of age, who has a variety of symptoms indicating nervous 
derangements, including the so-called "globus hystericus," and 
who, were he of the opposite sex, would unquestionably be pro- 
nounced hysterical. He has considerable tenderness of the testicles, 
and slight pressure upon these is all that is required to cause 
positive aggravation of all his symptoms. 

Heredity is the most prominent predisposing cause, though it 
is probable that a defective moral education by a hysterical mother, 
and the disposition of the child to imitate what it sees every day 
in its mother, partially accounts for the apparent influence of 
heredity. 

Depressing mental influences intensify, as it were, the predis- 
position, the nervous taint. Also erroneous education, excessive 
coition, masturbation, sterility, impotence of the husband, and an 
unhappy marriage in other respects, are enumerated as of etiolog- 
ical importance. 

Women frequently suffer from hysteria as a consequence of 
the exhaustion of the system due to lactation, menorrhagia or pro- 
longed illness, or from other causes which have induced a condition 
of general malnutrition. 



1) Principles and Practice of Gynecology, by Thomas A. Emmett, M.D., p. 184. 



HYSTERIA. 435 

Fritsch says that ' ' an explosion of hysteria is possible with 
every chronic gynecological affection." Prolonged irritation of the 
peripheral nervous regions lead to reflex neuroses. 

Symptoms. — The symptoms of hysteria, involving as they do 
every phase of nervous manifestation possible, both sensory and 
motor, defy any definite description. The peculiar mental disturb- 
ances of hysteria are well known. The rapid change of disposition 
is the most characteristic, a gay and lively mood rapidly alternat- 
ing with depression, sadness and weeping. The emotional nature 
is completely unbalanced, and storms of emotional excitement are 
liable to occur from the slightest causes, and often apparently 
from no cause or pretext whatever. The least contradiction may 
excite outbursts of anger, fits of laughing and floods of tears. In 
her inordinate desire for sympathy, the hysterical patient almost 
invariably exaggerates her sufferings and often the greatest deceit 
is willfully practiced in order to secure the sympathizing attention 
of her family and friends. This is often carried so far that such 
persons have inflicted wounds on themselves, and irritated them 
until the conditions became dangerous to life, or amputation, even, 
was demanded. Frogs and worms, feces and urine, have been 
swallowed in order to excite interest by their subsequent emesis. 

This mental condition is due to a defect in the higher reason- 
ing powers. Upon this point Dr. Fellows says (1): — "Emotions 
and passions furnish rapid and intense impulsion to act, and when 
the highest power, which makes choice of action impossible, is 
absent or much weakened, and the person is left under the control 
of these impulses, the result must be a capricious and unstable 
character. Differing, and often directly opposite, emotions being 
constantly excited, the resulting acts from these impulses must be 
of infinite variety; and this is what we find in the hysterical condi- 
tion. Hence we see that this lack of will is one of the great under- 
lying factors of hysteria, though it may vary greatly in different 
cases and at different times. It may be so completely lacking 
that the person will be turned by every trifling emotion, as is the 
weather-vane by every gust of wind. Hence the motives of choice, 
which it is the province of reason to furnish, remain, as it were, 
only theoretical concepts, powerless to inhabit or control emo- 
tional, automatic, and reflex impulsion. 

u The consciousness is often disturbed, or more or less in 
abeyance, perhaps completely so, in the gravest attacks of hysteria. 
But in very many instances where the woman is in an apparently 
unconscious state, the careful observer will appreciate the fact 
that she is quietly taking in all that is going on or that is being 
said about her. The wary practitioner will note this fact, and do 

1) Arndt's System of Medicine, Vol. II, p. 774. 



436 A TEXT-BOOK OF GYNECOLOGY. 

or say nothing in the presence of such a patient that he does not 
want her to know. At times he may avail himself of this oppor- 
tunity to make statements in her presence with the intention that 
they shall re-act on her mentally." Accompanying these mental 
states there may be hallucinations, and even delusions with maniacal 
excitement, to an extent that it becomes difficult to diagnosticate the 
condition from one of real insanity. In fact, hysterical patients 
sometimes become insane, though this is the exception. 

Erotism is not an unusual symptom, nymphomania usually 
occurring in women of a highly-wrought nervous organization and 
subject to hysterical phenomena. The sensory nerves are strongly 
affected, and give rise to sensations as varied in their character as 
are the mental manifestations. Hyperesthesia and neuralgia are 
always present to a greater or less extent. There may be increased 
sensitiveness to touch over the whole body. Especially are the 
joints liable to be hypersesthetic, particularly the knee and hip 
joints. This may even be swollen to such an extent that the case 
simulates arthritis. The neuralgic pains are usually temporary, 
and subject largely to mental influences. With great excitement, 
either of joy or sorrow, the most violent pains occur suddenly or 
disappear with equal abruptness. The typical headache, known 
as clavus hystericus, is a very intense pain, and is confined to a 
very small space, either in the occiput, in the region of the sagittal 
suture, unilaterally in the forehead, or in the eye-ball. Proso- 
palgia, toothache, intercostal neuralgia, sciatica and other varieties 
of neuralgia may be present. Often the neuralgia is located along 
the spine, giving rise to tenderness, thus simulating spinal irrita- 
tion. A characteristic of the pain, wherever located, is that it 
becomes more intense in proportion to the attention paid to it and 
the amount of sympathy manifested by friends, whereas, on the 
other hand, whenever the attention is distracted, the pain is either 
ameliorated or entirely ceases. 

Anaesthesia may be present, the sensitiveness to pain being 
usually diminished, while that to heat and touch remains. One 
half of the body may be affected, or isolated portions of skin, as 
the back of the hands and feet. Loss of the muscular sense pre- 
vents the patient, if the eyes be closed, from knowing what move- 
ments she has made. Anaesthesia of any of the mucous membranes 
may occur. The special senses are often impaired, amaurosis, 
deafness and disordered taste and smell being of no unusual occur- 
rence. 

In the motor sphere the symptoms are as protean as else- 
where, both convulsive and paralytic conditions being produced. 
Actual convulsions of an epileptic nature sometimes occur, giving 
a disease known as hystero-epilepsy, which has all the characteris- 



HYSTERIA. 437 

tics of epilepsy, though associated with it are the various mental 
and sensory manifestations already noted. More often the convul- 
sions are incomplete, and attack only certain groups of muscles, or 
perhaps amount only to a trembling and restlessness of the arms 
and legs, or slight clonic spasms of these or other parts. 

The so-called "globus hystericus" is a very constant feature 
of this disease, and it is still a question whether this is the result 
of motor or sensory disturbance. It consists of a sensation of a 
ball in the throat, or rising from the stomach to the throat, and 
causing choking. This is said to be analogous to the "aura" in 
epilepsy. The paralysis of hysteria may affect one limb only, or 
the arm and leg of one side, or the arm of one side and leg of the 
other. The levator palpebral superioris is frequently affected, but 
the facial and hypoglossal nerves are rarely involved. The paralysis 
may also affect the muscular walls of the oesophagus, stomach and 
intestines, and the laryngeal muscles, producing aphonia. 

Of the disturbances of the circulatory system the most im- 
portant is palpitation, with increased force of the apex beat. In 
some cases the heart's action fails, and there is syncope. Vaso- 
motor disturbances are seen in the pale skin, which does not bleed 
when pricked, and in the flushings and profuse sweatings which are 
often present. Salivation and polyuria often occur after a hysterical 
attack. The sphincter of the bladder is also at times spasmodically 
contracted. 

The visceral organs also sympathize in the general derange- 
ment. The stomach and the intestines are often distended by gas, 
and in connection therewith a peculiar hysterical colic exists. The 
patients also have a sensation of fullness, so that they believe that 
they have a swelling or tumor, and assert that it is impossible for 
them to close their dresses or tie their skirts firmly. 

Intractable, spasmodic, long-continued vomiting is likewise 
observed in hysteria. Withal the stomach can be quite healthy 
and tolerate even very heavy nutriment. Indeed, such patients eat 
nothing for days, and then suddenly voraciously swallow large 
quantities. Connected with this we find, of course, digestive dis- 
turbances, especially constipation. In other cases, although vomit- 
ing does not occur, a permanent hiccough renders the condition 
equally annoying. In the respiratory sphere, a dry, spasmodic, 
tickling cough, and a difficulty of breathing, known as hysterical 
asthma, are the most important symptoms. 

Diagnosis. — The diagnosis is often very difficult, and requires 
the exercise of the greatest caution and skill. The nervous man- 
ifestations of hysteria are so varied, and simulate those connected 
with so many grave organic diseases, that the difficulty arises in 
being able to positively exclude cerebral or spinal organic lesion. 



438 A TEXT-BOOK OF GYNECOLOGY. 

Often a great injustice is done persons suffering with serious or- 
ganic disease by too readily assuming the whole disturbance to be 
of a purely functional character. 

Hysteria may be diagnosticated from epilepsy by the history 
of the case, by the fact that consciousness is not lost, and by the 
fact that the convulsive seizures are more uniform and coordinated 
than in epilepsy. Then, too, an epileptic fit usually terminates in 
coma and profound sleep, which is not the case in hysteria. Hys- 
terical fits do not occur during sleep, and apparently are to some 
extent controlled in their appearance and intensity by the will of 
the patient. 

Hysterical paralysis is not usually complete, and may affect 
one or the other limb or arm, or the arm of one side and the leg 
of the other, which would not occur from cerebral lesion. Paral- 
ysis of the facial and hypoglossal nerves is seldom present, thus 
distinguishing it from hemiplegia. In hysteria there is always a 
normal reaction to the electric current, and there is no tendency to 
atrophy of the parts. From many forms of spinal and nervous 
diseases no positive rules of diagnosis can be given. Only a con- 
tinued knowledge of the course of the disease in a given case, and 
a study of its individual peculiarities as the disease progresses, in 
comparison with the course of other diseases which it may simulate, 
will finally solve the problem. If hysterical hyperesthesia so affect 
the joints as to simulate arthritis, it may be diagnosticated by the 
fact that the pain is around, and not in, the joint, and that it is not 
aggravated by forcing the articular surfaces together. From in- 
flammatory and other chronic diseases of the internal organs, hys- 
teria can often be distinguished only by careful and repeated 
physical examinations. Nor should the fact be overlooked that 
sometimes in real hysteria serious organic lesions supervene and 
demand our recognition and attention. 

Dr. Bruce (1) reports a case in which the patient had symp- 
toms of hysteria; there was no optic neuritis, or other indication of 
cerebral mischief, and yet the post-mortem revealed a large tumor 
in the tempora-sphenoidal lobe. 

Pkognosis. — Unless complicated with organic diseases hysteria 
seldom proves fatal. If the disease is hereditary, and the nervous 
system, both by birth and education, is peculiarly liable to its 
development, a perfect cure is seldom accomplished. Sometimes 
melancholia, or some other form of insanity succeeds, and the usual 
course of such an affection is followed. In mild cases, and those 
due to etiological conditions which are subject to control, a cure 
may be effected. Some cases recover spontaneously after the cli- 



1) Brain, part XXII. 1883. 



HYSTERIA. 439 

maxis. According to Fritsch, (1) " Those cases in which a single 
symptom is pronounced, even if to a high degree, are prognostically 
more favorable than cases of slight multiple hysteria." 

Treatment. — The moral treatment of an hysterical patient is 
of the utmost importance. Dr. Ludlam says (2): — "This disorder, 
being chiefly emotional in its origin, and, indeed, in its very 
nature, it is vitally important to obtain such an influence over the 
mind of the patient as will serve in a measure to control the 
symptoms, or at least to place her in a state in which our remedies 
will act more promptly and efficiently. There can be no doubt 
that very many cases of hysteria, in some of its protean forms, 
have been unwittingly cured by means that were suited to occupy, 
divert, overwhelm, or control the emotional faculties. Such 
expedients are to be regarded only as auxiliaries to proper treat- 
ment, but as such they are so useful, and sometimes so necessary, 
that they should not be overlooked. For it has often happened that 
the manner and bearing of the nurse, or of some kind-hearted 
neighbor who has been called in, has done a thousand times more 
to cure these patients than the physician's prescription. The in- 
tangible, but no less potent, influences of fear, faith, hope, confi- 
dence, will, reason, diversion, management, occupation of the 
mind, argument, concession, opposition, sympathy, indulgence of 
caprice, helping her to bear her burdens — whether real or imaginary 
— change of diet, air, and scenery are sometimes indispensable. 
And unless we can use them appropriately, or the patient shall 
happen to be accidentally brought under their influence, the best 
chosen remedies will utterly fail of effect. What the character of 
this mental treatment should be in any given case will be apparent 
to any physician possessed of tact and judgment, both of which 
are indispensable in the treatment of hysteria. Uniform kindness 
to the patient is necessary, but firmness and decision are equally 
so. Sympathy is sometimes required, though more often it will 
do more harm than good; nevertheless, the physician should not 
carry his lack of sympathy and consideration to such an extent as 
to lose the confidence of his patient, for this once done he can ac- 
complish very little for her after." 

If the patient is anaemic, as is usually the case, she should 
receive the ordinary hygienic treatment — systematic exercise in the 
open air, plenty of sunlight, nourishing and carefully regulated 
diet. Often a trip to the seashore, with salt-water bathing, will be 
of excellent service. In fact, a trip anywhere amongst congenial 
surroundings is often a benefit in hysteria. The patient grows 
weary of home, and any change is often desirable, provided that 



1) Op. Cit., p. 345. 

2) Lectures on the Diseases of Women, p. 



440 A TEXT-BOOK OF GYNECOLOGY. 

it is not to any crowded fashionable resort. Sometimes it is nec- 
essary that the patient be removed from the influence of too 
sympathizing friends, and often it is better that she leave home and 
be entirely with strangers in order to strengthen her will power. 
She should be made to avoid exciting amusements and novel-read- 
ing, or anything that tends to vitiate the mind and deprave the 
imagination. S. Wier Mitchell's treatment of uterine and ovarian 
diseases by means of rest, massage, feeding, electricity, etc. , which 
is fully described on page 182, has been found especially useful in 
the treatment of hysteria. 

Electricity, as ordinarily used, has often proved useful, but 
whether it really overcomes the nervous irritation, or simply acts 
upon the patient's imagination, cannot be told, though the latter is 
the probable explanation. But it matters little so long as benefit 
is derived from its use. Nor is the fact often forgotten that after 
the physician has treated a case of hysteria for a long time with- 
out accomplishing a cure, and is at his " wits' ends " as to what to 
do next, he can still continue the use of electricity. 

To relieve an hysterical paroxysm, many expedients aside from 
the use of remedies have been resorted to. The dashing of cold 
water into the face, or pouring it over the head or spine; holding 
the nose to stop the breath; introducing a rectal tube to allow 
accumulated flatus to pass off, have all in turn been tried. Some- 
times a full injection of hot water into the colon affords prompt 
relief. To this injection may be added, if necessary, an ounce or 
more of asafoetida. More often the administration of a little ether 
or chloroform will act the best, and speedily cut short the paroxysm. 
Occasionally this has been accomplished by simply pressing firmly 
upon the ovaries. 

Clitoridectomy has been resorted to in cases where erotism 
was prominent. Castration, or the removal of the ovaries, has 
been suggested, and practiced, but it is not justifiable save when 
the case is extreme and the cause positively referable to ovarian 
disease. So far as remedies are concerned it is evident that a 
disease covering such a vast range of symptoms may require almost 
any remedy in the materia medica, and such is indeed the case. 
Some remedies, however, are more useful than others, and to 
these only will I refer: — 

Anacardium. — Great weakness of memory; anxiety and feel- 
ing of impending misfortune; malicious; profane; feels as though 
she had two wills, one commanding to do what the other forbids; 
loss of confidence in herself and everybody else, hallucinations. 

Arsenicum. — Hysterical asthma at every little excitement; 
worse the latter part of night; she cannot lie down for fear of suf- 
focation; wants some water every few minutes; great fear of death. 



HYSTERIA. 441 

Asafcetida. — Throat and oesophagus chiefly affected; sensa- 
tion of a ball rising in throat, obliging frequent swallowing to 
keep it down, and causing at times difficult breathing; restless, 
anxious, unsteady, fickle, irritable; great distension of stomach 
and abdomen with flatus, with much belching; nervous palpitation; 
hypersensitive. 

Caulophyllum. — Hysterical paroxysm during menses or at 
puberty; dysmenorrhea; spasms of chest and larynx. 

Cimicifuga. — Hysterical spasms at time of menses, or follow- 
ing the disappearance of neuralgia; amenorrhea or dysmenorrhea; 
ovarian irritation, especially on left side ; pains like electric shocks 
or lancinating pains in various parts. 

Cocculus. — Choking constriction in the upper part of fauces, 
with difficult breathing and disposition to cough; retarded menses, 
which finally appear, with great weakness and nausea, even to faint- 
ness; roaring in the cars. 

Conium. — Vertigo in recumbent position; globus hystericus; 
during micturation her urine alternately flows and stops; the 
breasts swell, become hard and painful before the menses, when 
the hysterical symptoms increase. 

Gtelsemium. — Hysterical convulsions, with spasms of the 
glottis; hysterical epilepsy; excessive irritability of mind and body, 
with vascular excitement; semi-stupor, with languor and prostra- 
tion; nervous headaches, commencing in the neck and spreading 
over whole head; migraine; dysmenorrhea of a neuralgic or spas- 
modic character. 

Ignatia. — Changeable disposition; laughing and crying alter- 
nately; least blame or contradiction excites and irritates her; full 
of supposed grief, broods over imaginary troubles; frequent sigh- 
ing; sensation of a lump in the throat; difficult breathing; sensa- 
tion of weakness and sinking in pit of stomach, caused by grief 
or fright; twitches and convulsions or fainting fits and paralysis. 

Lachesis. — Loquacious; jealous; suspicious; sensation of lump 
rising in throat; uneasiness from least contact on throat or abdo- 
men; uterine and ovarian pains relieved by flow of blood; during 
climacteric. 

Lilium Tigrinum. — Depression of spirits, timid, weeping and 
apprehensive; tormented about her salvation; always in a hurry; 
profane; obscene thoughts; headache; bearing down in the uterine 
region; ovarian pains; pains in the chest; fluttering of the heart; 
ovarian irritation and inflammation; uterine inflammation or dis- 
placement. 

Moschus. — Chilliness over the whole body; great tendency 
to involuntary stools; copious, colorless urine; great restlessness 
of the lower extremities; long-continued scolding, until she falls 



442 A TEXT-BOOK OF GYNECOLOGY. 

down fainting; talks continually of her approaching death; frequent 
swooning; constriction of the chest; tetanic spasms; globus hys- 
tericus; great desire for beer or brandy. 

Nux Moschata. — Changeable mood, one moment laughing, 
the next crying; enormous distension of the abdomen after meals; 
leucorrhea in place of the menses; great sleepiness. 

Nux Vomica. — Quarrelsome, irritable, morose, easily excited; 
oversensitive to external impressions, such as a noise, talking, 
music, strong odors, etc.; easily offended; hypochondriac mood, 
worse after eating; dyspepsia; constipation; spasms renewed by 
the slightest touch ; hysteria from high living or spirituous liquors, 
or overuse of mind and sedentary habits. 

Palladium. — She imagines herself neglected; wounded pride; 
greatly inclined to use strong language and violent expressions; 
excited and impatient; distended abdomen, from flatulence; stools 
hard, like chalk; pain and weakness, as if the uterus were sinking 
down; every motion painful; great sleepiness, and feels better 
after sleep. 

Phosphorus. — Increase of sexual desire; great sense of weak- 
ness in abdomen, aggravating all other symptoms; eructations of 
wind after eating; sleepy after dinner. 

Platina. — Self -exaltation and contempt for others; strange 
titillating sensation, extending from genital organs upward into 
the abdomen; spasms, with wild shrieks; menses in excess, dark 
and thick; chilliness; no thirst; better out of doors; horrifying 
thoughts. 

Pulsatilla. — Morose, out of sorts, discontented and fretful; 
inclined to weep; dyspepsia; bearing-down pains in abdomen; 
amenorrhea; first menses delayed; pains and other symptoms con- 
stantly changing; worse evenings; better in the open air; most 
useful in patients with light or sandy hair and blue eyes. 

Sabina. — Very nervous and apprehensive; music intolerable; 
menorrhagia; tendency to abortion at third month; tired and indo- 
lent; pain from back through to pubis. 

Senecio. — Nervousness, sleeplessness and hysterical moods, 
with amenorrhea or dysmenorrhea. 

Sepia. — Nervous, irritable, fretful, sad and dejected; indif- 
ferent to everything, even her own family; mental and physical 
indolence; sensation of emptiness in stomach and abdomen; bear- 
ing-down in uterine region; displacements; leucorrhea, amenor- 
rhea, dysmenorrhea; exhaustion and faintness; want of natural 
warmth; sensitive to cold air, especially during child-bed or while 
nursing. 

Tarantula. — Hystero-epilepsy; chorea; great sexual excite- 
ment; paroxysms relieved by music. 



HYSTERIA. 



Theridion. — Time passes too quickly; vertigo and headache; 
sounds penetrate the teeth; during puberty or at climacteric. 

Zincum. — Nervous, fidgety moving of the feet, must move 
them incessantly; twitching and jerking in various muscles; feels 



better while menstruating. 



CHAPTER LVI. 



STERILITY. 



Synonyms. — Barrenness. Inf ecundity . 

Definition. — This term implies an incapability for concep- 
tion, but by common usage it is applied to all women who have 
never borne children, even though it has not been established that 
the failure to conceive is due to their incapacity. So also is the 
term sterility very appropriately applied to women who have a 
capacity for conception, but who remain childless, either because 
the fertilizing element in the male is wanting, or because, if con- 
ception does occur, the ovum does not mature. In the strict sense 
of the term such women are barren but not sterile. 

In a clinical work it is not necessary to more than briefly 
enumerate the various causes that may give rise to sterility in the 
true sense of the term — that is, those cases which produce an in- 
capacity for conception, having nothing to do either with an inca- 
pacity for gestation on the part of the female, or deficient virility 
on the part of the male. 

Neither is it, in the language of Dr. Barnes (1), "a part of 
the object of an essentially clinical work to dwell upon the moral 
or social aspects of this question. But it is strictly within the 
scope of medical discussion to observe that sterility is not summed 
up by saying that it is simply the negation of fertility. Complete 
sexual life in women implies the due succession of the functions 
of ovulation, of gestation, and of lactation. The ovaries, the 
uterus and the breasts ought, in the natural cycle or order, to 
relieve one another. Where the ovaries alone act continuously 
under the excitation of married life, a sense of an unfulfilled func- 
tion arises, which, in many organizations, is likely to induce phy- 
sical as well as mental disturbances. The familiar saying that 
women in a certain condition of health would be well if they could 
have children is a popular mode of expressing the physiological 
fact." 

Etiology. — Sterility may be either congenital or acquired. 
That is, it may be due to congenital organic defects, or it may 
arise from subsequent disease. However, the causes of sterility 
are not usually classified according to whether they are con- 
genital or acquired, but rather as to the method by which they 

1) Diseases of Women, p. 107. 

444 



STERILITY 445 

produce sterility. Thomas (1) tabulates the special causes of ster- 
ility as follows: — 

1. Causes preventing the entrance of semen into the uterus: 
Absence of the uterus or vagina; 

Obturator hymen; 

Vaginismus; 

Atresia vaginae; 

Occlusion of cervical canal; 

Conical shape of cervix; 

Cervical endometritis; 

Polypi or fibroids; 

Displacements; 

Very small os internum. 

2. Causes preventing the production of healthy ovule: 
Chronic ovaritis; 

Cystic disease of both ovaries; 
Cellulitis or peritonitis; 
Absence of ovaries. 

3. Causes preventing passage of ovule into uterus: 
Stricture or obliteration of Fallopian tubes; 
Absence of Fallopian tubes; 

Detachments and displacements of Fallopian tubes. 

4. Causes destroying vitality of semen or preventing fixation 

of impregnated ovum: 
Corporeal or cervical endometritis; 
Membranous dysmenorrhea ; 
Menorrhagia or metrorrhagia: 
Abnormal growths; 
Chronic metritis. 

These pathological states have already been fully considered 
under their respective heads, and do not require further elaboration. 

Other authors (2) have laid down as psychical causes: — Incom- 
patibility of temperament; frigidity; erotism. Several cases are 
on record where sterility has been the result of the connection of 
one husband and wife, while, after a divorce, both parties had 
issue by other mates. 

Coldness or absence of sexual desire is considered by some to be 
a cause of sterility. No doubt sterile women are frequently devoid 
of sexual feeling. But, on the other hand, there are many women 
who have never conceived, but, who are decidedly amorous in their 
disposition and desires. It is claimed by some that the cervix 

1) Op. Cit., p. 625. 

2) Hale on Sterility, p. 274. 



446 A TEXT-BOOK OF GYNECOLOGY. 

uteri, under strictly normal conditions, is capable of effecting an 
erection as complete as that which occurs in the male, and the 
mechanism is similar in both, erection and emission taking place 
in the female as well as in the male, and that conception will not 
take place unless this orgasm occurs. This may be true in some 
instances, but it certainly is not true as a general proposition. 

The influence of erotism or erotomania in preventing concep- 
tion I am not prepared to elucidate, but I am inclined to believe 
that erotic women are more likely to be prolific than otherwise. 

It is claimed by some authorities that any cause, of whatever 
nature, that produces dyspareunia, is a cause of sterility. Undoubt- 
edly this is frequently the case, but it should be borne in mind that 
as a rule these causes act in other and more certain ways to pro- 
duce sterility, than in the mere difficulty and pain of coition, there 
being usually some obstacle to the entrance of the semen into the 
uterus. 

The influence of painful menstruation upon conception, or at 
least the simultaneous occurrence of dysmenorrhea and sterility, is 
familiar to every physician. It is seldom that we are called upon 
to treat dysmenorrhea except in childless women, though not in- 
frequently conception occurs and cures the disease. Emmett 
shows by carefully prepared tables ' ' that of all married women 
who at puberty suffered pain during the flow, over 71 per cent, 
were sterile." 

The influence of gonorrhea in producing an incapacity for 
conception is now pretty generally admitted. Dr. Emil Ncegge- 
rath (1), in 1872, first called attention to a theory that gonorrhea 
remained latent in the system during the life of the individual. 
This has not been generally accepted by the profession, but one of 
his propositions, made in connection with that theory, namely, 
that the wives of those men who at any period of their lives have 
had gonorrhea, remain, as a rule, sterile, has received many sup- 
porters. Could that proposition be modified as follows: — "a 
woman who has once had gonorrhea remains as a rule sterile," I 
think it would express a pretty well established fact. I cannot 
enter into a discussion as to how this process sets up certain inflam- 
matory states in the pelvis which may cause sterility, nor is this 
necessary, as the subject is already well understood. 

Finally, I would call attention to the fact that in those causes 
destroying the vitality of the semen before it reaches the cervical 
canal, the chief factor is the acid character of the vaginal dis- 
charges. This may be simply an abnormally acid vaginal mucus, 
or it may be a leucorrheal or menstrual discharge of a like char- 
acter. The alkaline mucus of the uterus is favorable to the vitality 

1) Latent Gonorrhea in the Female, Bonn, 1872. 



STERILITY. 447 

of the spermatozoa, but when it becomes altered by disease it may 
cause their speedy death. 

Biegel has found that all of the following agents are de- 
structive of spermatozoa:— water, saliva, sour milk, alcohol, ether, 
chloroform, creasote, tannin, acetic acid, mineral acids, metallic 
salts, ethereal oils. 

Diagnosis. — Under this head it might be appropriate to 
mention the fact that an apparent lack of fertility in the female 
may be due to deficient virility in the male, and it is quite often 
important to ascertain if this be the case. It may prove difficult 
to obtain knowledge upon this point, as men are sometimes very 
averse to revealing any sexual deficiency in themselves, and will, 
as Dr. Thomas says, ' 4 often allow the supposition of sterility on 
the part of their wives to be maintained rather than admit the truth. " 
He says that ' l in two cases I have used an anaesthetic, ruptured the 
hymen, and distended the vagina, under the impression that 
sterility of several years' standing was due to the impossibility of 
the accomplishment of intercourse, and have subsequently discov- 
ered that the husbands of my patients were entirely impotent, and 
had been so before marriage." For this reason it is often difficult 
to procure their consent to an investigation. In such cases, if 
there is no history of impotence, or seminal weakness, and the 
organs are apparently normal in structure and function, it becomes 
necessary to test the semen microscopically. For this purpose a 
single drop is sufficient. It should be examined as soon after 
emission as possible, and before a low temperature or any other 
inimical influences may have been exerted upon it. If the semen 
does not contain spermatozoa, or if they are present, but motion- 
less, the man is sterile. 

Prognosis. — This depends entirely upon our ability to dis- 
cover and remove the cause, but as a general proposition it may be 
said that the treatment of sterility is decidedly unsatisfactory. In 
those cases where any of the essential organs of reproduction are 
absent or imperfectly developed, and in those where no cause can 
be ascertained, the prognosis is most unfavorable, the latter class 
probably consisting of those obscure mechanical or physiological 
impediments which can be neither discovered nor removed. 

Treatment. — This consists in the removal of the condition 
which is causing the sterility, if such a thing be possible. As Dr. 
Thomas well says : — "This affection is commonly only a symptom 
which should be reached through the malady which induces it. " 

The treatment of the various pathological states which may 
cause sterility has already been considered elsewhere, and need not 
be repeated. I will mention the fact only that where sterility 
arises from flexion or other obstruction of the cervical canal, the 



448 A TEXT-BOOK OF GYNECOLOGY. 

introduction of a slippery -elm tent makes a mild and perfectly safe 
substitute for the intra-stem pessary. It can be introduced in the 
morning and left till evening, at which time, upon removal, it leaves 
the canal patent for a sufficient length of time to attempt securing 
conception. 

No treatment for sterility alone should be undertaken that in- 
volves danger to the life of the woman, no matter how strong the 
desire maybe for an heir. As Dr. Thorburn (1) says: — "There 
is no necessity for informing the patient that you do not see the 
extreme necessity in the same light that she and her husband do. 
But operations of complaisance are always to be deprecated, and I 
would counsel that no risk should ever be incurred in such cases, 
beyond what would be considered advisable in the case of husband 
and wife who were simply desirous of the increased happiness of 
offspring, but who were sensible enough to deprecate any proceed- 
ings fraught with danger to life or permanent health." 

Concerning artificial impregnation, I shall say but little, re- 
garding it, as I do, as a process of exceedingly doubtful utility, to 
say nothing of its questionable propriety. It consists in the 
mechanical introduction of spermatic fluid into the uterine cavity 
in the following manner : — Coitus having been practiced in the usual 
manner, a small quantity of the semen is, within a few minutes after, 
drawn from the vagina into a properly constructed syringe which 
has been previously warmed to the normal temperature of the 
body. The tip of the syringe is then passed through the cervical 
canal to a point beyond the internal os, and a drop or two carefully 
discharged within the uterus. The tube is allowed to remain a mo- 
ment, and is then carefully withdrawn, the woman to remain 
quietly in bed for several hours. 

Grirault (2) prefers to the syringe a hollow sound for the 
introduction of the semen. The instrument, properly charged, is 
placed within the neck of the uterus, and the fluid is discharged by 
the operator's blowing through the tube. 

That artificial impregnation has been occasionally successful 
there can be no doubt, and if it is the urgent request of both hus- 
band and wife that this method be attempted, it might be wrong 
for the physician to object on merely ethical grounds. 

In his remarks on the general therapeutics of sterility Dr. 
Hale (3) says : — 

' ' By referring to the list of medicinal causes of sterility, it 
will be seen that the same medicines are enumerated that appear 
below as the curative agents in sterility. That this should be so, 



1) Diseases of Women, American Edition, p. 524. 

2) Etude sur la Generation artificielle dans TEspece Humain. Paris, 1869. 

3) Op. Cit. 



STERILITY. 449 

is in accordance with the law of cure, which asserts that only those 
medicines which cause diseases are capable of curing similar ones. 
No medicine, therefore, can cure sterility, without being capable, 
either directly or indirectly, of causing that condition." 

To this I might add that no medicine will cure sterility that 
does not possess in its pathogenesis the symptoms which the 
sterile patient presents, whether these be due to some local lesion, 
or to some obscure physical or mental condition, the pathology of 
which cannot be ascertained. 

Dr. Hale believes ' ' that nearly all medicines capable of 
causing sterility do so by their action on the ovaries," by interfer- 
ing with the important function of ovulation. This is probably 
true, but wmether it is or not does not matter so long as we adhere 
strictly to the symptoms of the case in the selection of a remedy. 

The following remedies should be consulted : Agnus Castus, 
Aletris, Apis mel., Belladonna, Borax, Baryta carb., Cantharis, 
Calcarea carb. , Cannabis sat. , Conium, Cimicif uga, Caulophyllum, 
Eupatorium purp., Helonias, Iodium, Kali brom., Mercurius, 
Phosphorus, Platina, Pulsatilla, Ruta grav., Sabina, Secale, 
Stillingia, Senecio, Sepia, Sulphur. 

Those who desire to make a more general study of the the- 
rapeutics of sterility are referred to Dr. Hale's book, already 
mentioned. 



CHAPTER LVII. 



EXTRA-UTERINE GESTATION. 



Synonyms. — Extra-uterine pregnancy. Extra-uterine fceta- 

tion. Ectopic gestation. 

Definition. — The fixation and development of the fecundated 

ovum at some point outside of the uterine cavity. 

Varieties. — The different forms of extra-uterine gestation 

are designated according to 
the location at which the 
fertilized ovum is arrested 
on its way to the uterus. 
The ovum becomes adher- 
ent at the point of arrest, 
and development takes 
place in like manner as in 
the uterine cavity. Hence, 
we have the following va- 
rieties:— (1) Tubal ; (2) 
Tubo-uterine, or, intersti- 
tial; (3) Tubo-ovarian; (4) 
Tubo-abdominal; (5) Abdo- 
minal; (6) Ovarian; (7) 
When occurring in a rudi- 
mentary horn of the uterus. 
There are also three 
very rare varieties known 
as the utero-tubal, utero- 
tubo-abdominal and sub- 
peritoneo-pelvic. In the 
first named of these the 
placenta is in its normal 
location within the uterine 
cavity, and the foetus in 
the Fallopian tubes. In the 
utero - tubo - abdominal the 
placenta is within the ute- 
rus and the foetus in the 
abdominal cavity, the two 
being connected by an um- 
bilical cord passing through 

450 




Fig. 195.— Tubal gestation 



EXTRA-UTERINE GESTATION. 



451 



the tubes. In the sub-peritoneo-pelvic variety the ovum develops 
within the folds of the broad ligament. 

1. Tubal Gestation.— This is the most common form of 
extra-uterine gestation, and comprises all cases in which the point 
of attachment of the ovum is in the course of the Fallopian tube 
between the uterine and abdominal extremities. 

By far the greater proportion of cases occur in the central 
part of the tube. In tubal gestation the covering is composed 
solely of the walls of the tube. 

2. Tubo-Uterine, or, Interstitial Gestation. — This va- 
riety comprises those cases in which the ovum is arrested in that 
portion of the tube which passes through the uterine wall. It is 




Fig. 196.— Tubal gestation. 

of rare occurrence. In most instances in which the ovum becomes 
attached at the point indicated, it develops in such a way as to 
dilate the ostium uterinum, its future growth extending into the 
uterus or its walls. In this variety the covering is composed of 
the uterine tissue and the wall of the tube. 

3. Tubo-Ovarian Gestation. — When the point of attach- 
ment is at the fimbriated extremity of the tube, development takes 
place toward the abdominal cavity, an attachment being formed 
also with the ovary, which, together with the tube and the pro- 
ducts of a localized inflammation, constitutes a membranous cover- 
ing or capsule for the ovum. According to Bandle, (1) "The 



1) Diseases of the Tubes, etc. 
Wood & Co. 



Cyclopedia Obstetrics and Gynecology, Vol. XII, p. 52, W. 



452 A TEXT-BOOK OF GYNECOLOGY. 

tubal wall often does not follow the developing ovum, but becomes 
thinned, and bursts at one or another point, at which place inflam- 
matory exudations occur; and occasionally the effused blood forms 
a secondary capsule for the ovum. 

' c Localized peritonitis and the resulting inflammatory products 
cause adhesions of the outer covering of the ovum with the neigh- 
boring structures, broad ligaments, ovaries, omentum, intestine, 
bladder and uterus. Also by constant formation of false mem- 
branes, and repeated rupture of the same in the gradual develop- 




Fig. 197.— Interstitial gestation. 

ment of the ovum, it becomes adherent to distant organs, the 
spleen, kidney or liver. The placenta is usually found in the 
pelvic portion of the abdominal cavity. 

' ' This gradual pathologico-anatomical formation of the outer 
covering of the ovum explains why pregnancy lasts longer in these 
cases, even occasionally to term, or the child may be carried 
beyond the normal time." 

4. Tubo-Abdominal Gestation. — This variety differs from 
the last mentioned only in that none of the investing structures is 
ovarian. The symptoms and course are the same. 

5. Abdominal Gestation. — If the ovum drops into the 
peritoneal cavity either in an impregnated state, or, if it becomes 
impregnated afterward, as some claim, abdominal gestation occurs. 



EXTRA-UTERINE GESTATION. 453 

Undoubtedly abdominal gestation is also frequently secondary to 
tubal or ovarian gestation, impregnation taking place in the tube 
or ovary and foetal development progressing to a point when the 
sac gives way; but, according to Barnes, (1) "the ovum is not- 
cast out of its original attachments. Inflammation of the peri- 
toneum is excited by the rupture and effusion of blood; neighbor- 
ing organs get connected by adhesions with the sac; the embryo 
and its envelopes grow into the new space; fresh effusions of 
lymph are thrown out surrounding all, and thus a new sac is formed 
in which it is difficult to trace the original tubal structure." 

According to Klob the ovum develops from the point where 
it is in contact with the abdominal wall, where cell proliferation 
of the connective tissue partly surrounds it, which through extra- 




Fig. 198.— A lithopsedion. 

ordinary vascularity makes it possible for a placenta to develop. 
The sac thus formed often attains a degree of thickness which 
renders it comparable to the walls of a gravid uterus. 

In secondary abdominal gestation, when rupture of the sac 
and foetal membranes occur allowing the foetus to pass into the 
abdominal cavity, the foetus usually dies within a short time, but 
development may continue, a secondary sac being formed, as pre- 
viously described. If death of the foetus occurs, the latter may 
become petrified, forming what is termed a lithopsedion, (Fig. 198.) 
or by aid of the surrounding vascular tissues the soft structures of 
the body may be preserved for years. Hecker and others main- 
tain that abdominal gestation is more frequent than tubal. 

6. Ovarian Gestation. — This term is applied to those cases 
in which the fecundation and development of the ovum takes 

1) Diseases of Women, p. 376. 



454 



A TEXT-BOOK OF GYNECOLOGY. 



place in the Graafian follicle. The possibility of ovarian gestation 
has long been a disputed point, but well authenticated cases now 
on record seem to have established the question in the affirmative. 
Nevertheless some authors still maintain that the starting point of 
all such cases is at the abdominal end of the tube. On the con- 
trary, Schrceder holds that many cases described as abdominal 
were really ovarian. Bandl is of the opinion that the origin of 
ovarian pregnancy is easily accounted for; he claims that after the 
bursting of a follicle the ovule remains in the ovary, and by some 
cause there becomes impregnated, but is prevented from escaping 
and following its proper course. The walls of the Graafian fol- 




Fig. 199. — Abdominal gestation. 



licle and the ovarian stroma furnish for the ovum a membranous 
envelope, which resembles the wall of an ovarian cyst. 

7. Gestation in a Rudimentary Horn of the Uterus. — 
This form of gestation, while intra-uterine, is, in its character and 
results, equivalent to interstitial gestation, and cannot be distin- 
guished from that variety during life. Nor, indeed, is it always 
possible to differentiate between the two in the cadaver, for in both 
instances the round ligament extends in an outward direction; 
whereas, in tubal gestation the ligament is situated between the 
sac and the uterus. 

Thomas, while recognizing the varieties of extra-uterine gesta- 
tion above described, claims that " the tubo-ovarian,, tubo-abdominal, 
ovarian, and some other varieties are niceties beyond the apprecia- 
tion of diagnosis," and that the gynecologist " is forced to limit him- 
self as far as practice is concerned to the classification of all varieties 
into (1) tubal, (2) interstitial and (3) abdominal pregnancies. " 



EXTRA- UTERINE GESTA TION. 



455 



Uterine Changes in Extra - Uterine Gestation. — The 
changes which take place in the uterus daring extra-uterine ges- 
tation are much the same as in normal pregnancy. The uterus 
becomes larger, softer, more vascular, and a decidua forms in its 
cavity. These changes are most marked in the interstitial variety, 
and become less in proportion to the distance of the point of attach- 
ment from the uterine cavity. As a rule the changes do not last 




Fig. 200. — Gestation in a rudimentary cornu. 

long, the uterus returning to its normal size and condition whether 
or not the development of the ovum continues. What has been 
said of the uterus also holds true as to the vagina and mammae, 
which, in the first stages of extra-uterine gestation, undergo the 
changes incident to pregnancy. 



456 A TEXT-BOOK OF GYNECOLOGY. 

Etiology. — Extra-uterine gestation may be caused by any 
condition that gives rise to an occlusion or mechanical obstruction 
of the tubes. Among these conditions may be catarrhal inflam- 
mation of the tubes themselves, or pelvic inflammation resulting 
in adhesions. The latter operates by causing angulations and con- 
strictions of the tubes, thus retaining the fecundated germ in the 
ovary, preventing its entrance into the Fallopian tube, or arresting 
its progress after its entrance. Polypi, either at the entrance or 
in the course of the tubes, have also caused obstruction and given 
rise to extra-uterine gestation. Paralysis, spasm and insufficient 
length of the tube have been ascribed as causes. Migration of the 
ovum is also laid down by some authors as a cause of extra-uterine 
gestation, but this opinion is not generally accepted. Parvin ob- 
serves (1) that "in some instances the oviduct may be sufficiently 
pervious for spermatozoids, but not for the ovum, but in others it 
is completely closed in some part of its course, and then there 
must have been either transmigration of the ovum, or transmigra- 
tion of the spermatozoids; in the first case the impregnated ovule 
comes from the opposite ovary, and in the second the spermato- 
zoids come through the opposite tube, then make their way across 
to the ovary corresponding with the impervious duct." 

Symptoms. — The symptoms of extra-uterine gestation are 
neither definite nor distinct. At first, in some cases, there may 
be no symptoms whatever, while in others the ordinary symptoms 
of pregnancy are manifest, though they usually present a degree 
of irregularity not common in normal pregnancy. Thus, the 
menses may be present or absent, and, if present, either scanty or 
profuse; and often there is hemorrhage, or a discharge of clots, 
which have been mistaken for portions of the placenta. The mam- 
mary sympathies are excited in most cases, and the changes in the 
areola take place. The patient may or may not suffer from nausea 
or vomiting, and in some cases at an early period the foetal move- 
ments have been felt by the patient. Abdominal pain is usually 
complained of at an early date. This pain may be intermittent in 
character, but is generally constant, and limited to one spot, that 
being usually at the site of the enlargement, if there be any. 
According to Dr. Perry the pain is quite characteristic. He says 
(2) that c ' often at the end of the fourth week, often not until the 
end of the second month, the woman is seized with a violent pain 
usually described as colic, and situated in the hypogastric region, 
generally on one side. The pain is very severe, and often produces 
profound prostration, with pallor, cold, clammy perspiration, feeble 
or nearly imperceptible pulse and even syncope. It is generally 

1) Science and Art of Obstetrics, p. 305. 

2) Leishman's System of Midwifery, 2d American Edition, p. 199. 



EXTRA-UTERINE GESTATION. 457 

associated with marked and even very great tenderness in the 
lower part of the abdomen, which has led some to mistake this 
condition for peritonitis. After a period of variable duration, 
from a few hours to one or two days in most cases, the severity of 
the pain diminishes, or it may disappear entirely. The calm, how- 
ever, is deceptive, for sooner or later another paroxysm sets in, and 
pursues the same course that the first did. These attacks of pain 
continue to recur at intervals, until rupture occurs, or until after 
the fifth or sixth month of gestation." 

The pain and the symptoms of inflammation which may also 
accompany it are supposed to result from a partial rupture of the 
sac, or, more often, the limiting adhesions are being stretched or 
torn, and new ones forming. This may continue until term, or 
even beyond, but such instances are rare, rupture of the sac 
most often occurring before the third month. This is accounted 
for by the fact that the tubal variety is most frequent, and in this 
form early rupture of the sac is almost a certainty. Usually the 
symptoms consequent upon rupture are the first to cause alarm, and 
the physician being hurriedly summoned, finds that after a sudden 
and violent attack of pain, with a simultaneous diminution in the 
size of the tumor, the patient is in a state of collapse, with 
pallor, dimness of vision, vomiting, syncope, and other symptoms 
which indicate profuse internal hemorrhage. If the hemorrhage 
be arrested either by natural or artificial means, the symptoms 
gradually disappear, and the patient rallies. But in most cases no 
such result follows; the pulse becomes weaker, the patient is cov- 
ered with a cold sweat, often convulsions supervene, and death 
rapidly follows. Should the patient rally from the collapse, there 
is liable to be a return of the hemorrhage within a few days, and if 
this does not occur there is danger that the contents of the sac, 
together with the effused blood, may give rise to a violent and rap- 
idly fatal peritonitis. 

Should development progress beyond the fourth month, pres- 
sure symptoms become manifest, especially difficulty and pain in 
micturition and defecation. These are caused by the falling of the 
sac into the pelvis, usually into Douglas' pouch. Should adhesions 
be present, preventing the descent of the sac, pressure symptoms 
are wanting. If development still continues, the physical signs of 
advanced pregnancy appear. Foetal heart sounds are heard, the 
movements of the child are distinct, and the tumor resembles that 
of a gravid uterus, except that it is located a little to one side of 
the median line. 

Diagnosis. — The diagnosis of extra-uterine gestation is a 
matter of the greatest importance, yet it is usually attended with 
considerable difficulty, and often cannot be positively established 



458 A TEXT-BOOK OF GYNECOLOGY. 

at an early stage. Tubal gestation is sometimes recognized early 
by the presence of a tumor in the region of the tube, accompanied 
by the usual signs of pregnancy, but other varieties are very 
rarely diagnosticated in the early stages. According to Bandl, 
(1) "Sudden and violent internal hemorrhage after previously 
good health in a pregnant woman, together with the passage of 
decidua, will warn us that extra-uterine pregnancy is present." 

At the time of rupture of the sac the condition is generally 
mistaken for pelvic hematocele, the symptoms of pain and collapse 
being precisely the same, and unless a history of pregnancy be 
present even a presumptive differentiation is possible. 

If the woman survive such an early rupture, the effused blood 
sometimes forms a tumor larger than the foetal sac itself. This often 
renders the diagnosis between a simple hematocele and an early 
extra-uterine pregnancy almost or quite impossible. 

In the later stages of development the difficulties are some- 
what lessened, but even here the most careful and persistent 
examinations by all the methods at command are required before 
anything like a positive diagnosis can be established. After the 
fourth month the ovum is as large as two fists, and, unless the 
abdominal walls are very thick, may be quite distinctly traced, 
even to the contour of the foetus. Sometimes a bi-manual exami- 
nation with the patient under the influence of an anaesthetic is 
required to establish the relations which the tumor holds to the 
uterus, and to demonstrate also the condition of the uterine walls 
and the emptiness of the uterine cavity. For the latter purpose 
the sound affords the most valuable aid, but it should not be em- 
ployed unless there is a reasonable certainty that intra-uterine 
pregnancy does not exist, remembering that it is possible to have 
both intra- and extra- uterine gestation at the same time. The same 
holds true in regard to the dilatation of the cervical canal with 
tents, and an exploration of the uterine cavity with the finger, which 
is recommended by Thomas. 

At this stage, unless the patient's condition demands immediate 
interference, which is not likely to be the case, it is better to post- 
pone giving a positive opinion until the physical signs of advanced 
pregnancy appear — active movements and the foetal heart sounds 
— after which there can be no question as to the presence of preg- 
nancy, the only point remaining to be determined, if it has not 
already been done, being the question of the intra- or extra- uterine 
location of the foetal sac. 

Before the symptoms of advanced pregnancy have appeared 
there is danger of confounding extra-uterine pregnancy with the 
following conditions : — 



1) Op. Cit., p. 80. 



EXTRA-UTERINE GESTATION. 459 

1. Normal or retroflexed gravid uterus; 

2. Pelvic hematocele; 

3. Ovarian cyst; 

4. Cyst of the broad ligament; 

5. Fibroid tumor; 

6. Pelvic exudations or abscess. 

The fact that the tumor lies distinct from the uterine body, 

and that the uterine cavity is empty, differentiates from the first 

condition named, unless intra- and extra- uterine gestation co-exist, 

which fact would greatly complicate the diagnosis. From the other 

conditions named a diagnosis may be established by the rules 

which have elsewhere been considered, under the respective heads. 

Thomas, whose large experience in the diagnosis and treatment of 

extra-uterine gestation entitles his words to great weight, says (1) 

"that in some cases ballottement, clear and distinct as that which is 

gotten in normal pregnancy, lends us its aid and makes diagnosis 

certain; in others the aspirator clears up the case; while in others 

still, where, for example, the question lies between a cyst of the 

broad ligament and extra-uterine pregnancy, cutting into the sac 

by means of the incandescent knife will combine diagnosis and 

treatment in a most satisfactory manner." 

The diagnosis of the different varieties of extra-uterine gesta- 
... . & 

tion in the early months is impossible. If the gestation has lasted 

four or five months without rupture, the chances are that it is ab- 
dominal, and almost certainly not tubal. Thomas lays clown some 
rules to aid in determining the variety, but they are not reliable, 
as he himself admits, and need not be given. 

Termination. — More than four-fifths of the cases of extra- 
uterine gestation result fatally. According to Kiwisch the mor- 
tality is 82.5 per cent. In tubal gestation rupture usually occurs 
about the second, third or fourth month, followed, as we have al- 
ready seen, by hemorrhage, peritonitis and death. In ovarian and 
abdominal gestation rupture does not usually occur before the 
eighth or ninth month. Should only partial rupture occur, the 
sac being more or less surrounded and protected by adhesions, the 
effused blood may be absorbed, and the patient rally, only to suffer 
from another partial rupture sooner or later as the ovum increases 
in size, which may follow the same course as the first. At other 
times the ovum may degenerate or the foetus die, and the whole 
become converted into a so-called mole; or, becoming encapsulated 
by processes of inff animation, it may become mummified; or, 
either with or without these changes, it may become calcified, 
forming a lithopaedion. In the latter case the calcified product 
may be carried many years without fatal results, or even without 

li Diseases of Women, 5th ed., p. 770. 



460 A TEXT-BOOK OF GYNECOLOGY. 

any noticeable systemic disturbance. Cases are on record where a 
lithopaedion has been carried fifty years. At any time, however, 
a lithopaedion may give rise to fatal peritonitis. It is a somewhat 
remarkable fact that women carrying a retained extra-uterine ovum 
have repeatedly become pregnant, and have been delivered of 
healthy children at full term without disturbing the retained ovum. 

In some instances after the death of the foetus a suppurative 
inflammation is established in the sac, and the patient dies from 
peritonitis; or fistulous openings may form through the intestines, 
abdominal walls, vagina or bladder, and the foetus be discharged 
in pieces, followed, in most instances, by the recovery of the patient, 
though death not unfrequently occurs from septicaemia, or from 
exhaustion due to the long-continued drain upon the system. 

In case extra-uterine gestation goes on to full term without 
accident, the period is marked by the usual pains characteristic of 
normal labor, a fact which is of remarkable physiological and 
clinical interest. 



CHAPTER LVIII. 

TREATMENT OF EXTRA-UTERINE GESTATION. 

The treatment of extra-uterine gestation may be either symp- 
tomatic or curative. 

Symptomatic treatment consists in the relief of the pain by 
the use of remedies and external applications. The remedies most 
often required are Belladonna and Colocynth, according to indica- 
tions. Also consult Apis, Arsenicum, Bryonia, Cantharis, Cimi- 
cifuga, Terebinthina and Veratrum album. 

Dry heat may be applied over the abdomen, but it is not safe 
to use fomentations. 

The patient should at all times exercise great care to avoid 
any jar or shock, the lifting of heavy weights, severe exercise or 
long journeys, or doing anything that might cause rupture of the 
sac. As much time as possible should be spent in the prone posi- 
tion. The bowels should be kept moderately loose by means of 
appropriate diet, remedies and enemata, in order that straining at 
stool may be avoided. 

If rupture occur, the patient should be placed at once in the 
horizontal position and ice applied to the abdomen, or a hot water 
spinal bag applied to the lumbo-dorsal region. The aorta may be 
compressed, though this is not a very satisfactory expedient. If 
there be great prostration and collapse, stimulants should be 
administered, and sulphuric ether be injected hypodermically. 
Any one of the following remedies may be prescribed, according 
to circumstances: — Aconite, Arnica, Digitalis, Hamamelis, Phos- 
phorus, Millefolium, Secale, Terebinthina, Thlaspi. 

The curative treatment of extra-uterine gestation is necessarily 
surgical in its character, and is best considered under three dis- 
tinct heads: — 

1. During early stage; 

2. During advanced stage, the foetus still living; 

3. During advanced stage, the foetus being dead. 

Before detailing the various methods of treatment employed, 
I desire to quote a few observations from Thomas, who has prob- 
ably had a larger experience in the treatment of these cases than 
any other surgeon, certainly than any other American surgeon, and 
whose statements are of exceptional value and should be carefully 
considered. In the first place. Dr. Thomas does not favor either 

461 



462 A TEXT-BOOK OF GYNECOLOGY. 

complete non-interference or surgical measures, in the treatment 
of cases of extra-uterine gestation, but claims that "on a middle 
ground, one lying between those extremes, the truly conservative 
surgeon will find his appropriate position." He then continues as 
follows (1):— 

' ' Let us in the beginning recognize the fact that, do what we 
will — remain utterly inactive, or use the greatest surgical enter- 
prise — the issue of these unfortunate cases will be bad. And let 
every surgeon be sure that he does not shirk a dangerous opera- 
tion because he fears the odium which will probably attach to a 
fatal result, and which he would avoid if he simply allowed his 
patient to die without an effort. 

" He who cannot bear unjust censure and endure without 
complaint an odium which he does not deserve, was not born to 
be a surgeon, one of the greatest functions of whose life this is; 
and under the grave responsibilities which attach to the conduct of 
a case of ectopic gestation it is the bounden duty of such an one 
to place his patient's interests in stronger hands. The statement is 
true everywhere in surgery, but nowhere is its truth more strik- 
ingly apparent than in these cases, that every personal considera- 
tion, every private interest, should yield to the good of the patient. 

"One point which may be regarded as entirely settled in the 
treatment of extra-uterine pregnancy is this: a secondary operation 
for discharge of the contents of the foetal sac is always safer than 
a primary one. But its antithesis must likewise be recognized — 
it may become hazardous to discard a primary operation and to 
expose a patient to the delay involved by waiting for a secondary 
one. The rule for interference should then be this: delay is wise 
so long as it is the offspring of prudence-, it is culpable as soon as 
it becomes the dictate of timidity and indecision." 

1. Treatment During the Early Stage of Gestation. — 
This consists either in (1) the primary removal of the entire sac 
and its contents by laparotomy, or elytrotomy, or, (2) in imitating 
nature by adopting measures to cause the death of the embryo. 
(3) Laparotomy after rupture of the sac. 

(1 . ) Primary removal. — It having been definitely ascertained 
that an extra-uterine gestation exists, and if the case has the ap- 
pearance of a tubal gestation, and, especially, if it be giving rise 
to severe symptoms, we may seriously consider the advisability of 
the removal of the sac and contents before rupture occurs. In 
cases where an opportunity for an early diagnosis has been had, 
Bandl and others advise immediate surgical interference. This 
may be accomplished by either of two methods: — a. Laparotomy, 
b. Elytrotomy. 



1) Op. Cit., p. 773. 



TREATMENT OF EXTRA-UTERINE GESTATION. 463 

a. Laparotomy. — This operation is performed precisely in 
the manner of ovariotomy, and, as Bandl says, ' ' there is no reason 
why we should not attain as good results as in that operation." 
The broad and ovarian ligaments and the Fallopian tube are included 
as a pedicle in a ligature, and the foetal mass is removed. 

b. Elytrotomy. — In cases where the severity of the symp- 
toms demands immediate interference, Thomas recommends, if the 
tumor be certainly accessible from the pelvis, that it "be cut freely 
into by a dull, incandescent point, like the knife of Paquelin's 
therm o-cautery, the foetus removed, hemorrhage controlled by a 
firm tampon, septicaemia prevented by antiseptic injections, and 
the placenta allowed to come away itself." 

(2.) Measures to cause the death of the embryo. — These are: — 
a. electricity; b. injections into the sac; c. aspiration; d. puncture. 

a. Electricity. — The Faradic current is used, the negative 
electrode being introduced into the rectum, and the positive placed 
over the tumor, and a moderate current employed for about ten 
minutes. This should be repeated every day, until the diminution 
of the foetal cyst and the retrograde changes in the breasts show 
that gestation has been definitely arrested. Usually four or five 
sittings are required. Dr. Blackwood, (1) who has used electricity 
successfully in five cases of extra-uterine gestation, advocates the 
application of a strong current continued for an hour, and but a 
single application. 

b. Injections into the sac. — The injection of atropia, strych- 
nia or morphia to destroy the foetus has been successfully prac- 
ticed. Morphia has been most extensively used. It is said to 
produce but slight inflammatory disturbance, and to have but little 
narcotic influence upon the maternal system. The injection is 
made through the vaginal or abdominal walls by means of a long 
and slender hypodermic needle, ten to fifteen drops of Majendie'S 
solution of morphia being used. 

c. Asjnration. — This consists in drawing off the liquor amnii 
by means of a very small aspirating needle, under antiseptic pre- 
cautions. Several instances are recorded where cures have been 
accomplished by this method. 

d. Puncture. — This operation has been successfully employed 
several times, but is very frequently followed by septicaemia and 
peritonitis, and has been severely condemned by several observers 
of wide experience. The operation is performed through the 
deepest place in the posterior vaginal wall, by means of a long, 
curved trocar. It has also been performed through the rectum. 
As the use of the trocar necessarily admits air, involving the dan- 
ger of septicaemia, it is obvious that aspiration, while answering 

1 ) Philadelphia Medical Times, 1886. 



464 A TEXT-BOOK OF GYNECOLOGY. 

the indications of the operation equally well, is a much safer 
method. 

The death of the embryo having been accomplished by either 
of the methods mentioned, it is then better to leave subsequent 
events to nature, keeping careful watch of the case and being ready 
to remove the sac and its contents at any time when the symptoms 
indicate such a necessity, using either of the methods already 
described, laparotomy or elytrotomy, according to individual cir- 
cumstances. 

(3.) Laparotomy after rupture of the sac. — Notwithstanding 
the mortality that has in the past attended this operation for the 
relief of the cataclysmic symptoms resulting from the rupture of 
an extra-uterine foetal cyst, it is coming into greater favor as our 
knowledge of abdominal surgery increases. 

Kiwisch, many years ago, held the opinion that, since death 
can hardly be averted in any other way, it is proper to open the 
abdominal cavity and stop the hemorrhage directly. 

Bandl (1) says that "this proposal of Kiwisch's was made 
at a time when the results of ovariotomy were by no means so 
favorable as they are to-day; and we can certainly remove from 
the peritoneal cavity such dangerous contents as blood, liquor 
amnii and fragments of tissue. 

c fc The difficulty in the diagnosis and the fact that other affec- 
tions, especially hematocele, often have very much the same symp- 
toms of internal hemorrhage, will limit the applicability of the 
operation. " 

Thomas says (2) he " would now assume laparotomy to be the 
only legitimate resource in these cases when sufficient delay has 
been practiced to convince the practitioner that death is surely 
approaching." 

According to Kiwisch the operation is performed as follows: — 

' ' In the first place the abdominal cavity must be freely 
opened (six to eight inches), with the usual precautions, along the 
linea alba. The peritoneal incision might at first be made only a 
few lines in length, and by the introduction of a warm sound and 
careful pressure, a certainty of the presence of blood in the peri- 
toneal cavity be obtained. If there is blood the opening should be 
completed, and the pelvic contents made thoroughly accessible. 
Next, we must find the bleeding point. The hand is to be intro- 
duced into the abdomen, and the uterus lifted up, and, if it is not 
itself the seat of an interstitial pregnancy, its appendages are to 
be carefully followed out on the side of the tumor. It may be nec- 
essary first to remove the effused blood. The rupture discovered, 

1) Op. Cit., p. 86. 

2) Op. Cit., p. 777. 



TREATMENT OF EXTRA-UTERINE GESTATION. 465 

the ovum or its remains are to be at once extracted. If the ovum 
is already in the abdominal cavity, its removal may be deferred 
till later. In accordance with the structure of the seat of hemor- 
rhage the bleeding point must be seized with the forceps and 
wholly or in part tied with long ligatures, or, if the edges of the 
wound need it, they must be united by a fine needle and moder- 
ately thick silk. If, as will most often probably be the case, this 
does not suffice to check the hemorrhage, Ave might in tubal cases 
extirpate the entire sac, using the same procedure as the ovarioto- 
mists do. After hemorrhage has entirely ceased we can proceed to 
thoroughly remove the effused blood by means of fine, warmed 
sponges, and then replace the intestines and close the abdominal 
wound, passing the ends of the ligature out through it. " 

Bandl suggests that, as in modern ovariotomy, the liga- 
tures should be cut short, and the usual antiseptic precautions 
observed. 

2. Treatment During the Advanced Stage, the Fcetus 
Still Living. — It is generally admitted that a case of extra-uter- 
ine gestation having advanced beyond the period ordinarily possi- 
ble for tubal distension and consequent rupture, should not be in- 
terfered with before full term, unless the symptoms imperatively 
demand such interference, which usually is not the case. The only 
disputed question is as to the advisability of operating at term. 
Bandl, Thomas and other recent writers advocate operating, while 
Parvin holds (1) that "the deplorable mortality of the operation to 
the mothers gives us to the present time a negative answer." 
Thomas says (2) that "at full term an effort at labor usually 
occurs and gives a signal for action. Should this most fortunate 
event occur, the crowning triumph of obstetric surgery may be 
reached in the delivery of a living child from a living woman at 
full term, as was done by Jesop, of Leeds, in a case reported to the 
London Obstetrical Society a few years ago. 

" At the present day, when abdominal surgery is so thoroughly 
s} 7 stematized, and so fully understood, and when the great contri- 
butions of the illustrious Lister have so completely altered its 
results, it is worse than useless to quote the statistics of laparotomy 
for extra-uterine pregnancy collected by Campbell and others. A 
new departure must be made in the subject, and the future must 
make its own record." 

As to the time of operation, Bandl observes that ; ' Kiwisch 
long ago noticed the danger of waiting for expulsive pains, and no 
time should be lost. " He has also ' ' seen the beginning of the pains 
mark the turning point in the woman's fate," and holds that oper- 

1) Op. Cit., p. 314. 

2) Op. Cit, p. 775. 



466 A TEXT-BOOK OF GYNECOLOGY. 

ative interference should take place as soon as the end of pregnancy 
appears to have been reached, without waiting for expulsive pains. 

This operation may also be performed either by (1) lapa- 
rotomy or (2) elytrotomy, the choice of procedure depending upon 
the situation of the sac. 

(1.) Laparotomy. — As a rule this is the most suitable pro- 
cedure, for the reason that the greater part of the foetus lies above 
the pelvic brim. The operation is performed entirely according to 
the rules of ovariotomy. The linea alba marks the line of incision. 
According to Bandl (1) ''the chief danger of the operation, while 
the child is alive, lies, as Lintzmann has shown, in the relations of 
the placenta and the placental circulation. If the placenta is 
attached to the anterior sac wall, and we can hardly ascertain that 
until we have made the incision, a very serious hemorrhage will 
inevitably occur. In fact most of the cases operated upon have 
perished from this cause. We must either avoid this hemorrhage 
or control it. And now-a-days, when much greater technical diffi- 
culties in operations upon abdominal tumors and organs have been 
overcome, it is to "be hoped that we shall succeed in this also. We 
might puncture the ovum in another place, quickly enlarge the 
foetal sac, and extract the child, after passing an elastic ligature 
around the placenta; or perhaps by enlarging the abdominal incision 
we might be able to open the sac at some other place; or we might 
after puncture push the placenta vessels to one side, put an elastic 
ligature around them, open the sac, extract the child, and extirpate 
the whole membranous bag. 

c l Subsequent to the operation we must take great care that no 
injurious secretions are allowed to collect, and that purulent 
remains of the embryo find free outlet through the abdominal 
wound. We shall often have purulent collections, especially in 
Douglas' cul-de-sac. If possible they should be evacuated by 
puncture or incision. ,, 

(2.) Elytrotomy. — This method is advisable in those advanced 
cases where a large part of the foetus lies in the pelvis, the head or 
buttock depressing and thinning out the posterior vaginal vault. 
The operation consists in making an incision in the vaginal wall, 
and through it seizing and removing the child by means of obstet- 
rical forceps. Bandl recommends passing the hand through the 
wound into the cavity of the ovum, and extracting the child by the 
feet. He then ties the cord with an aseptic thread, level with the 
surface of the wound, and stuffs iodoform gauze into the vagina 
and wound. Naturally, no attempt is to be made to remove the 
placenta, only those membranes and shreds of tissue which appear 
at the level of the wound being taken away. A few days later we 

1) Op. Cit., p. 92. 



TREATMENT OF EXTRA-UTERINE GESTATION. 467 

may try, by gentle traction, to see if we cannot remove the 
placenta without creating excessive hemorrhage. 

Under these circumstances the peritoneal cavity is usually not 
opened by the operation, on account of the multiple adhesions of 
the sac. If no attempt is made to remove the placenta the woman 
will lose but little blood. The large incision permits the free out- 
flow of discharges, and everything is in the most favorable 
condition for healing. If the secretions begin to smell, and fever 
appear, we should freely inject disinfecting fluids, or, if necessary, 
apply drainage. 

3. Treatment During the Advanced Stage, the Fcetus 
Being Dead. — Under these circumstances the expectant plan of 
treatment should be adopted, and no operation performed until the 
symptoms of the case demand it. The great danger lies in hem- 
orrhage and septicaemia. According to Thomas, 4 ' the longer time 
that the placenta remains attached after foetal death, the more 
certain is it to become atrophied and consequently less vascular," 
therefore the less danger of hemorrhage. Also, ' ' the more thor- 
oughly the foetal envelopes become disgorged and atrophic from 
loss of function, the less likely is this dangerous complication (sep- 
ticaemia) to develop." All authorities agree that no operation 
should be performed until it is certain that the placental circulation 
has ceased, unless the symptoms of the case imperatively demand 
immediate interference. 

Thomas advises kk judicious delay and cautious Avaiting for 
symptoms indicative of approaching trouble," but he says kk such 
delay, such waiting, are by no means to be carried so far that symp- 
toms of septic absorption shall occur." In case this does happen, 
the opening of the sac should not be delayed, as the subsequent use 
of antiseptics is calculated to restrain the pernicious influence 
of the decomposing contents upon the entire organism. 

The operation for the removal of the foetal cyst is, practically, 
the same as ovariotomy, and is easy or difficult according to the lo- 
cation of the sac, and its relation to the pelvic contents. Accord- 
ing to Schroeder, the entire foetal sac should be extirpated when 
possible. If, on account of adhesions to adjoining viscera, this 
cannot be done, the sac should be opened under strict antiseptic 
precautions, and thorough drainage provided. If the sac lie low 
in the pelvis, it may be best to resort to elytrotomy, as already 
described, but the results of the operation are not so favorable in 
these cases as in those where the foetus is still living. 

In case nature is making an effort to eliminate the remains of 
the foetus by the abdominal wall, the vagina, the rectum or the 
bladder, these efforts should be encouraged by all possible means. 
Sinuses should be kept open, and even enlarged, and the remains 



468 A TEXT-BOOK OF GYNECOLOGY. 

of the foetus extracted wholly or in pieces. According to Bandl, 
(1) "the longer these natural efforts at elimination last, the more 
adhesions are there of the sac; and the opening of the abdominal 
cavity is not much to be feared in later operative procedures. " 

Bandl also claims "that past experience shows us that we need 
not fear active operative interference in these cases; and it is to be 
recommended that incision of the abdominal walls or the vagina, 
or the enlargement of fistulous tracts, be not shrunk from when 
nature points out the road of elimination. The supporting sac 
left after total or partial extraction of the foetus is to be treated as. 
an ordinary abscess cavity." 

1) Op. Cit., p. 98. 



CHAPTER LIX. 

DISEASES OF THE MAMMARY GLANDS. 
Amazia. Polymazia. Retracted Nipple. Sore Nipples. 

In the female the breasts form a part of the sexual apparatus, 
and their intimate relation to the sexual organs proper renders the 
consideration of the diseases to which they are subject important 
to the gynecologist. 

Amazia. 

Definition. — A congenital absence of the mammary glands. 

It must be remembered that the mammary glands differ very 
materially in size in different women, and that there is no fixed 
relation between their size and that of the body, so that a woman 
may have these glands only very slightly developed and yet be 
perfectly normal. Not unfrequently the glands are so small in 
virgins and sterile women that their presence defies detection, yet 
upon the advent of pregnancy they develop with remarkable ra- 
pidity. Great inequality in the size of the breasts sometimes exists 
in the same woman, one breast being of normal size and the other 
very small, but rarely entirely absent. In nearly all women the 
right breast is larger and heavier than the left. Congenital absence 
of one or both breasts is of rare occurrence. The condition is 
usually observed as coincident with an absence or incomplete de- 
velopment of the ovaries, uterus or vagina, but this is not neces- 
sarily the case, as instances are reported where the mammary 
glands were absent and the genital organs perfectly normal. 

Polymazia. 

Definition. — The presence of more than two mammary 
glands in the same individual, — supernumerary mammary glands. 

According to Meckel von Hernsbach the embryo of the human 
female contains the germs of five mamma?, as in the bat; two are 
situated in the middle of each half of the thorax, one in each axilla, 
and one above the umbilicus just beneath the sternum. 

Numerous cases are reported in which three, four and five 
mamma? have been developed. 

A very interesting case has been reported recently by Dr. 
Bechtinger of Brazil (1) where two supernumerary mammary 



1) Annals of Gynecology. July, 1888. 



470 A TEXT-BOOK OF GYNECOLOGY. 

glands exist in a woman who also possesses two complete and 
separate vulvae and vaginae and three legs. The third leg is attached 
to a continuation of the processus coccygeus of the os sacrum. 
Besides the two well developed mammae in their natural position 
a third one, which is double, is seen above the os pubis. The 
hair surrounding the lower segments of the abnormal mammae 
covers the two vaginae with well developed vulvae. Both vaginae 
are properly supplied with nerves, and normal sexual connection, 
with correspondingly natural sensations, is possible in either vagina. 
The sexual appetite is markedly developed. She is twenty-five 
years of age, a native of Martinique, her father a Frenchman, her 
mother a Quadroon. She is still living, but left her native country 
for France about a year ago. 

Robert reports a case in which milk could be drawn from a 
supernumerary mamma on the outer surface of the left thigh; the 
mother of the patient had a double nipple. Billroth has observed 
only one case of double nipple. Winckel says he has never seen 
two or more nipples on the same breast, I have seen a case in 
my own practice where two nipples exist in the left breast, which, 
contrary to rule, is considerably larger than the right breast. The 
larger of the two nipples is situated one and one-half inches above 
and to the left of the centre of the breast, while the smaller nipple 
lies one and one-half inches below and to the right of the centre, 
the two nipples being three inches apart. The larger nipple seems 
entirely normal, except in location, while the smaller nipple has 
very slight areolae. During lactation both nipples discharge milk, 
but no attempt has ever been made to have a child nurse from the 
smaller one. It is also an interesting fact that in the left breast 
the nipple is similarly situated, and below and to the left of it 
exists a peculiar mark which is evidently an undeveloped nipple. 

Retracted Nipple. 

This malformation arises from a shortness of the excretory 
milk ducts, and is of comparatively frequent occurrence. These 
ducts may have been congenitally short, or the condition may 
have been brought about by inflammatory processes during infancy 
or early childhood. 

As it is impossible to lengthen the ducts there is no available 
method of treatment, either surgical or medical. 

Sore Nipples. 

During lactation the formation of fissures and cracks in the 
nipples, accompanied by more or less excoriation and even ulcera- 
tion, is of no uncommon occurrence. Sometimes the irritation 
extends to the cellular tissue about the nipple, and even to the 
glandular structure, resulting in mammary abscess. 



TREATMENT OF THE MAMMARY GLANDS. 471 

Treatment. — Prophylactic measures are of the utmost im- 
portance. It is customary during the latter months of pregnancy 
to harden the skin covering the nipple by the use of astringent 
lotions, such as tea, tannin or a decoction of white oak bark, but 
I believe such a custom should be deprecated for reasons that are 
mentioned in the chapter on mastitis. 

Nursing from the affected breast must cease entirely, or the 
nipple must be protected by a shield or some suitable application. 
For the latter purpose some use a solution of gutta-percha and 
chloroform, which dries and forms a protective pellicle which does 
not dissolve when the child nurses. Balsam of Peru or Tolu, with 
or without gum arabic, oil of almonds or rose-water, cerate of 
castor equinus, collodion, with or without glycerine, may be used 
as a protection. Gold-beaters' skin, perforated and applied over 
the nipple, is a good protective. Yolk of an egg, four parts, with 
glycerine, five parts, forms an excellent protective varnish. 

I have found either a lotion or glycerole of calendula to be 
the best curative application. Hamamelis, Hydrastis, Arnica, 
Phytolacca, or Tannin may be used in the same manner. A cerate 
of Graphites, or Graphites 2d trit., dusted over the nipple, is 
often of benefit. Pulverized gum arabic, hydrastin or boracic 
acid dusted on the nipple are highly recommended, as is also 
repeated washings with a five-per-cent. solution of carbolic acid. In 
very bad cases lead water may be used, or a weak solution of 
nitrate of silver, and if these do not answer touch the fissures and 
new surfaces once or twice with lunar caustic. The nipple should 
always be washed off both before and after the child nurses. 

Internal remedies are often of benefit, according to the local 
and constitutional symptoms present. The following are most 
often required: Argentum nit., Arnica, Belladonna, Calcarea carb. , 
Calendula, Chamomilla, Graphites, Hepar sulph., Iodine, Lycopo- 
dium, Mercurius, Nux vom., Phytolacca, Silicea, Sulphur. 
Dr. Leavitt gives the following indications (1): — 

Nipples itch, burn, look red: Agaricus. 

Nipples sore from nursing: Argentum nit. 

Nipples ulcerated: Calcarea carb. 

Nipples ache, and feel sore: Calcarea phos. 

Nipples nearly ulcerated off in neglected cases: Castor 
equinus. 

Nipples bleed much, and are very sore : Lycopodium. 

Nipples feel very raw and sore : Mercurius. 

Nipples ulcerate easily, and are very sore and tender : 
Causticum. 

Nipples inflamed and very sensitive : Chamomilla. 

1) Science and Art of Obstetrics, p. G08. 



472 A TEXT-BOOK OF GYNECOLOGY. 

Nipples dark, brownish red; unbearable pain on slightest 
touch; breasts full, skin hot, pulse strong : Colchicum. 

Nipples very sore to the touch; pain from nipple to 
scapula of same side whenever the child nurses : Cro- 
ton tig. 

Nipples painful, inflamed, cracked : Graphites. 

Nipples very sensitive, will not bear contact with the 
clothing : Helonias. 

Nipples sore, fissured, or covered with scurf ; bleed easily: 
Lycopodium. 

Nipples itch, and have a mealy covering : Petroleum. 

Nipples very sensitive : Phytolacca. 

Nipples sore and fissured, with intense suffering on 
putting the child to the breast; pain seems to start from 
the nipple and radiate over the whole body : Phy- 
tolacca. 

Nipples sore to touch, and sore and painful spot under 
right nipple : Sanguinaria can. 

Nipples sore; they itch and bleed : Sepia. 

Nipples cracked across the crown : Sepia. 

Nipples drawn in like a funnel : Silicea. 

Nipples cracked; after nursing they burn and bleed : 
Sulphur. 

Nipples painful during nursing, though there is but little 
appearance of soreness : Nux vom. 

Nipples in the first days of nursing feel sore, as if bruised: 
Arnica. 



CHAPTER LX. 

MASTITIS. MASTODYNIA. 
Mastitis. 

Synonyms. — Mammitis. Inflammation of the breast. Ab- 
scess of the breast. 

Definition. — Inflammation of the mammary gland, involv- 
ing the entire parenchyma, or being confined to the milk ducts and 
sinuses. The term is also improperly applied to an inflammation 
of the superficial connective tissue of the breast, originating in the 
subcutaneous tissue of the areola, and also to those rare cases of 
submammary inflammation, or paramastitis, where the connective 
tissue between the gland and the thorax becomes inflamed, and 
usually followed by extensive suppuration. 

Varieties. — Mastitis may be either acute, sub-acute or 
chronic, and puerperal or non-puerperal, the non-puerperal variety 
being of rare occurrence, notwithstanding the situation of the 
gland is such as to expose it to all sorts of accidents. 

Pathology. — The exact pathology of parenchymatous masti- 
tis at its outset is largely a matter of conjecture, and is based 
upon clinical rather than anatomical observations. According to 
Billroth, (1) "the gland is never affected at once in toto (as usually 
appears to be the case in parotitis), but inflammatory foci are 
formed in the gland, which may remain separate, but which as a 
rule gradually coalesce, and suppurate together. The foci may be 
considered partly as non-escaping milk, surrounded by inflamed 
tissue, partly as suppurating inflammatory foci, situated in the con- 
nective tissue between the acini." 

According to Klob's observations, "the affected parts seem 
hard, and usually form nodular tumors, section of which shows 
them to be distended with milk; the glandular tissue is hypersemic 
and very succulent. In the acini, small extravasations of blood, 
the size of a pin's head, may be seen. As a rule, suppuration oc- 
curs early, and appears to me, indeed, to be a connective tissue 
suppuration; at least I could not discover anything in such cases 
which would indicate an epithelial suppuration. Pus appears at 
first in the acini, partly fluid, partly not, and, as it seems to me, 
most frequently with fibrous intercellular substance, so that we find 

1) Diseases of the Female Mammary Glands, W. Wood & Co., p. 18. 

473 



474 A TEXT-BOOK OF GYNECOLOGY. 

in the grouped acini heaps of yellowish, fibrinous plugs, analogous 
to those found in croupous pneumonia. Destruction soon over- 
takes the finer interacinous tissue, the small purulent foci coalesce, 
forming larger ones, the pus becomes fluid and the true mammary 
abscess is formed. The cavity of this abscess never has a smooth 
wall, but the membrane is rough, and, not infrequently, nodular, 
and ragged particles of broken down gland tissue are found pro- 
jecting from it." 

Billroth' s observations lead him to conclude that l ' the inflam- 
matory irritant must proceed from the acini themselves or from 
their immediate surroundings," but he has also found by experi- 
ments upon animals that ' l there are channels of dissemination for 
inflammatory processes, which follow the ramifications of the 
gland; these can only be the blood- and lymph- vessels, which sur- 
round the ducts and lobules. I might maintain that it is most 
probable that the irritative material is distributed with the lymph 
through the gland, and thence acts upon the capillary net-work 
around the lobules, that the leucocytes emigrate and produce the 
purulent infiltration of the tissue immediately surrounding the 
lobules and the iracini. As to whether the pus cells are formed 
more from themselves or from the connective tissue cells of the 
interstitial tissue, I cannot say. At all events, capillary stasis, 
thrombosis and necrosis of the tissue result so far as this is not 
already the subject of cell infiltration. As regards the ' fibrinous 
purulent' plugs, which Klob found in the small abscesses of purulent 
lobules, I would prefer to look upon these as necrotic glandular and 
connective tissue. One may easily observe this change in suppura- 
tion of the subcutaneous tissue. I have not been able to convince 
myself of the formation of fibrin in mastitis, at least in the cases I 
have carefully examined, and would prefer, therefore, not to accept 
too readily the comparison with the finer processes of croupous 
pneumonia, which I have carefully studied. Further researches 
are necessary to prove that the process described by me in the tissue 
in puerperal mastitis is constant. These researches are now of new 
interest, as there is such a growing inclination to attribute all such 
infectious suppurations to the growth of micrococci." 

The secretion of milk is arrested in the affected lobules. If 
a large duct be perforated by the suppurative process, pus may be 
discharged with the milk through the nipple, or, on the other 
hand, a milk fistula may be established at some other point. Some- 
times, instead of the purulent foci existing at the same time and 
coalescing, they may suppurate in succession, and keep up a series 
of abscesses lasting weeks and even months. 

Etpology. — Puerperal mastitis is now regarded as being most 
often the result of diseased nipples, in a majority of cases arising 



MASTITIS. 475 

from the introduction of septic material through a wound of the 
nipple. A lymphangitis is thus established which extends to the 
deeper structures of the gland. 

According to Sappy, nine times out of ten mammary angeiole- 
ucitis begins by a crack, a fissure, an erysipelas, in a word some 
irritation seated at a point of the nipple or of the areola. 

Probably mastitis sometimes arises from a stasis of milk in 
the duct, but modern investigations seem to prove that, as Roser 
claims, the stagnation of milk is the result and not the cause of 
the inflammation. However, it is well known that a weakness of 
the child, in consequence of which the breasts are not thoroughly 
emptied of their contents, or undue pressure exercised upon the 
gland by misfitting dresses, producing obstructions in single tubes 
of the gland, does result in milk stases followed by inflammation. 
The view that bacteria may enter the milk ducts through the nipple 
and excite inflammation has never been proved, and is scarcely 
worthy of consideration. 

Inflammation of the superficial connective tissue may arise 
from external injuries, bruises, exposure to cold, or emotional 
disturbances, such as fright. The superficial inflammation thus 
established may extend inward and involve the parenchyma of the 
breast, giving rise to inflammation and subsequent suppuration. 

Non-puerperal mastitis may result from injury of the nipple, 
or from pressure, blows or falls upon the gland. In some instances 
no exciting cause can be ascertained, but in such cases a scrofulous 
diathesis is usually present. The cause of mastitis in newly-born 
children is unknown. 

Symptoms. — The advent of puerperal mastitis is usually 
marked by a chill, followed by an increased temperature and 
frequent pulse. The breast is the seat of sharp, shooting pains 
and one or more lobules will be found hard, irregular in form, and 
sensitive to pressure. The more superficial the inflammation, the 
more probably there will be seen fine red lines proceeding from 
the vicinity of the nipple, and indicating lymphangitis, but these 
are not present if the disease be deep-seated. The inflammation 
may involve only a small portion of the gland and be soon dissi- 
pated by appropriate treatment, or a small abscess may form, the 
patient recovering at once upon the evacuation of the pus. More 
often, however, the inflammation extends from one lobule to 
another until the greater part of the organ becomes involved. Even 
here resolution may be brought about, but more often suppuration 
occurs about two weeks after the first appearance of inflammation. 
The formation* of the abscess is indicated by the usual signs of sup- 
puration, rigors, fever, throbbing pain, and finally, if the pus 
approaches the surface, redness and circumscribed fluctuation. If 



476 A TEXT-BOOK OF GYNECOLOGY. 

the abscess break spontaneously, the suppurating process may ter- 
minate at once, or a fistulous passage may be produced and the 
suppuration continue. At other times the process may be protracted 
for weeks and even months by the formation of a succession of 
abscesses which greatly exhaust the patient by the continuous 
drain thus made upon the system. Very rarely blood-vessels 
become eroded and fatal hemorrhages occur. Sometimes the entire 
gland, or a greater part of it, becomes destroyed by the long con- 
tinued suppuration, and if the cavity of the abscess be considerably 
exposed to the air, the sloughing tissues may become gangrenous 
and septicaemia follow. 

Prognosis. — The prognosis is almost invariably favorable so 
far as the life of the mother is concerned, though, should the sup- 
puration be long continued, the drain upon the system may greatly 
exhaust the patient, and, if she be tuberculous, may cause a fresh 
outbreak of tubercles in the lungs. Death may in very rare 
instances occur from septicaemia. As a rule, if attended in time, 
proper treatment will dissipate the inflammation before pus has 
formed, or, suppuration having once commenced, it may be kept 
limited to a small portion of the gland. 

If resolution occur without suppuration, the secretion of milk 
will usually continue, and nursing may be resumed. This may 
also be the case after a small abscess has formed, but if a consider- 
able portion of the gland has been involved it is probable that the 
organ has been rendered permanently useless. 

Treatment. — The preventive treatment of mastitis is of great 
importance, but does not receive the attention it should. Dr. Julia 
Holmes Smith gives some excellent advice upon this subject, which 
is worthy of repetition. She says (1): — 

' ' All pressure upon the mammary glands should be avoided 
from earliest infancy. The use of high-cut stays with stiff bones 
cannot be too strongly deprecated. A constant use of cold-water 
sprays upon the breasts assists in their development and hardening. 
No false modesty should prevent a mother from carefully instruct- 
ing her daughter as to the use of these glands and the care neces- 
sary to keep them in a perfectly healthy condition during preg- 
nancy. Gentle massage may be practiced by the woman herself, 
rolling the breasts forward between the hands, and drawing the 
nipples forward in as close imitation as possible of nursing. This 
will do much toward hardening and preparing the glands for the 
vigorous attacks of a hungry baby. The old fashion of applying 
astringents, such as tannin and glycerine, is to be deprecated. It 
toughens the surface, but while it overcomes undue sensitiveness, 



1) Arndt's System of Medicine, Vol. II, p. 521. 



TREATMENT OF MASTITIS. -177 

it clogs the orifice of the milk ducts at the nipple, bringing about 
the very obstruction which is sought to be avoided. 

ik The child should be put to the breast as soon after labor as 
possible, for the action of the child's mouth determines the flow 
of the blood to the gland and prepares it for the work of secretion. 
Besides, the close relation of the mammae and uterus makes lacta- 
tion a very valuable factor in producing involution, and very often 
putting the child to the breast will produce uterine contractions, 
and so control hemorrhage. 

"Too much cannot be said in favor of nursing the child at 
regular intervals. Too frequent and irregular nursing keeps up 
glandular irritation tending toward inflammation, as a perpetual 
dragging at the nipples may lacerate them. The indifferent mother 
who empties the breast at too long intervals may cause mischief 
from over-distension of the milk ducts and lobules. The tiniest 
fissure should receive careful attention, the child applied to the 
healthy breast, and the tender nipple covered with a shield. Touch- 
ing the fissure with nitrate of silver, using a camers-hair brush, has 
been found useful. Covering the tract with compound tincture 
of benzoin or collodion is also good. If the nipple is too sore for 
the child to use, even with a shield, the infant should be made to 
take the bottle for a few days or until the fissures are healed, the 
milk meanwhile being expressed by massage." 

At the very first indications of inflammation the appropriate 
remedy should be selected and perseveringly administered. The 
indications for remedies will be subsequently considered. 

The child should be removed from the affected breast at once, 
and the gland kept as nearly as possible in a state of perfect rest; 
no rubbing or handling should be allowed, and the breast pump is 
not to be used, except when the breast becomes so distended with 
milk as to cause pain, when partial relief only should be secured 
by a careful use of the pump. If the flow of milk be excessive, 
camphorated oil or a plaster of lard and camphor may be applied. 
The breast should be supported by a bandage, unless the method 
of treatment by systematic and equable pressure be adopted. The 
latter plan is deserving of special mention. It was first detailed 
by Dr. P. A. Harris, as follows (1): — 

kt Having discovered the existence of an inflammatory move- 
ment in the breast, of any grade of severity, or at any stage of 
advancement, short of the formation of an abscess, I should at 
once interdict nursing, friction, pumping, the application of fo- 
mentations, in fact every local measure excepting such as are cal- 
culated to secure complete rest for the gland; rest from passive 
motion, rest from secretion, and rest from pain. All these con- 

i 

1) American Journal of Obstetrics. Jan., 1S85. 



478 A TEXT-BOOK OF GYNECOLOGY. 

ditions can, in a great degree, be immediately secured for the 
patient. Procure at once a roll of soft cotton-wool, cotton batting, 
a plain roller bandage at least twenty yards long and two or two 
and a quarter inches wide, also eighteen large safety pins. The 
breast is first covered with a layer of cotton-wool, and the bandage 
so applied as to lift up and compress the affected organ. The 
patient should be seen daily, and the bandage reapplied until the 
crisis is passed; this time varying from one to several days." 

Dr. E. H. Grandin says that this method of treatment has 
been followed for several years in the New York Maternity Hos- 
pital ' ' with the very best results, and under its uniform use we 
never, at this institution, have occasion to interfere surgically with 
the puerperal breast." 

Dr. Hiram Corson strongly advocates (1) treating mammary 
inflammations by applications of ice, stating that during twenty- 
seven years in which he has employed it, he has failed in no instance 
to disperse the inflammation, if suppuration had not already 
occurred, and at the same time brought comfort to the patient. 
He states : l ' There is no better way to apply the ice than to put 
it into the bladder with just enough water to float it, or just to 
form a water cushion, that will fit the inflamed part nicely. It is 
not necessary to put two thicknesses of muslin between the blad- 
der and the breast; it is not too cold without any, but a single 
thickness is useful to keep the bladder in place more readily." 

In all local applications warmth is to be avoided as long as 
there is hope of preventing suppuration; but should this occur, as 
shown by occasional chills, and the swelling becoming soft and 
superficial, a large flaxseed poultice may be applied. An excep- 
tion to this rule is when a poultice of fresh root of phytolacca is 
applied, which, in the first stage, will frequently dissipate the inflam- 
mation. If the fresh root cannot be obtained, the breast may be 
kept covered with cloths wrung out of hot water in which has been 
placed a small quantity of phytolacca tincture. 

As soon as the signs of suppuration appear the abscess should 
be opened. If the pus be deeply seated, and its location not easily 
ascertained, it is better first to insert an aspirator needle. The 
incision should be made at the most dependent point in the abscess, 
and should be parallel with the lacteal tubes. 

Billroth, Kormann, and Kucher advise the introduction of a 
drainage tube. 

Billroth adopts the following plan in opening a mammary 
abscess (2): — 

The breast is at first carefully cleansed with soap, and then 



1) American Journal of Obstetrics, 1881. 

2) Op. Cit,, p. 25. 



TREATMENT OF MASTITIS. 479 

with a weak carbolic acid or thymol solution. The incision should 
be made in the direction of the radius of the gland, about thirty- 
six inches long, and down to the pus focus, and must be immedi- 
ately followed by the insertion of a drainage tube, which is kept 
from slipping in by the use of a safety-pin. Gentle pressure is 
then made upon the gland, so as to force the pus out through the 
drainage tube; the breast is again washed with some disinfecting 
solution, the patient being in the recumbent position; the whole 
breast is covered in with Lister-gauze, waterproof dressings over 
this, and then, over all, especially below and toward the axilla, is 
placed a large quantity of salicyl-jute, and the whole dressing is 
then fastened with a bandage extending over the entire thorax from 
the neck to the umbilicus. In doing this care should be taken to pack 
sufficient cotton beneath and around the sound breast to prevent 
its surface from being pressed into contact with that of the throat. 
If the abscess is large and sinuous, the dressing should be changed 
in twenty-four hours, and then should be left in place for from 
three to five days. By these means the organ is equably com- 
pressed, the pus is prevented from decomposing, and the discharge 
is promoted, all conditions which tend to produce a painless course 
and a rapid recovery. If, while the bandage is applied, the 
patient once more suffers from pain and fever, it should be 
removed, and any new abscess in the process of formation should 
be opened and treated in the same manner. 

By the practice recommended, even in bad cases, the ugly 
scars and deformities of the breast, which sometimes follow the 
older poultice treatment, are avoided. 

In fresh cases the pus is never decomposed, and irrigation of 
the wound is unnecessary. In old cases, on the contrary, which 
have been treated by small incisions and without antiseptic precau- 
tions, the pus is often acid, and possessed of irritating properties. 
For these neglected abscesses Billroth recommends placing the 
patient under an anaesthetic and enlarging the opening so as to per- 
mit the passage of the finger, and breaking down the thin partitions 
between the abscesses so as to convert them, so far as possible, into 
large, communicating cavities; while this process is going on the 
tube of an irrigator should be passed by the side of the finger, and 
the cavity should be washed with a three-per-cent. solution of car- 
bolic acid until at last the fluid comes away clear and unstained. 
Drainage tubes should then be introduced and the breast treated 
antiseptically in the manner already described. 

Whenever a compression bandage is required it will be found 
that compressed sponge will answer an excellent purpose. It is 
prepared as follows : 

Take a large, flat sponge that will completely cover the mam- 



480 A TEXT-BOOK OF GYNECOLOGY. 

mary gland, and after it is thoroughly cleaned, put it in a letter- 
press for a few hours, or otherwise secure its compression; then 
place it over the breast, which is first covered by a layer of cotton 
batting, and apply a bandage. After the application of the band- 
age a little water is allowed from time to time to pass through it, 
moistening the sponge, which consequently swells and thus more 
and more compresses the gland, bringing the abscess walls in 
perfect contact. 

Therapeutics. 

The following remedies are most often required : — 

During the inflammatory stage — Aconite, Arnica, Belladon- 
na, Bryonia, Phytolacca, Pulsatilla. 

After suppuration has commenced Mercurius will sometimes 
check it and cause absorption of the existing pus. Hepar sulphur, 
given in a high attenuation, is said to avert a threatening suppura- 
tion. On the contrary, if suppuration is inevitable, Hepar sulphur 
should be given in a low attenuation, to hasten the process. This 
should not be done, however, so long as there is any possibility of 
averting the disaster. 

If suppuration becomes established, but, after opening, the 
abscess does not heal, the suppurative process persisting and some- 
times fistulae forming, Silicea is the remedy. 

The following are the most common indications for the reme- 
dies that have been found useful in mastitis. 

Aconite. — Mastitis caused by exposure to cold. Chill fol- 
lowed by fever; restlessness, anxiety, fear. 

Apis. — Burning, stinging pains in the breast; considerable 
swelling and hardness; erysipelatous inflammation. 

Arnica. — Mastitis following bruises and injuries of the breast. 

Belladonna. — Breasts feel heavy, with great hardness and 
swelling; red streaks radiating along the course of the milk ducts; 
throbbing or stitching pains; headache; constipation; scanty urine. 

Bryonia. — Breasts swollen, very tender, hard, with little or 
no redness; stitching pains worse on motion or deep inspiration; 
milk scanty or suppressed. 

Carbo Animalis. — Darting pains in mammae, arresting breath- 
ing; worse from pressure; hard, painful spots; swollen, inflamed. 

Croton Tiglium. — Breasts hard and swollen; when nursing, 
a very severe drawing pain runs directly from mammae through 
to the back. 

Graphites. — Many old cicatrices from former inflammations 
nearly prevent the milk from flowing. It causes the milk to flow 
easily and wards off abscess. 

Hepar Sulphur. — When suppuration seems inevitable, to 
hasten the process. 



MASTODYNIA. 481 

Lachesis. — Breast has a purplish appearance; lancinating 
pains in the breast and down the arm. 

Mercurius. — Especially when after Belladonna, suppuration 
sets in; breast hard and swollen; rigors; throbbing. Mercurius 
may cause absorption and bring about resolution after pus has 
formed. Also in cases where suppuration takes place in different 
parts of the breast. 

Phosphorus. — Phlegmonous inflammation. Breasts swollen; 
red in spots or streaks; hard knots m different places, with fistu- 
lous openings, with burning, stinging pain and watery, offensive 
discharge; hectic fever and night sweats. 

Phytolacca. — All things considered, this is probably our 
most valuable remedy in mastitis. At the onset it may be used 
externally as a lotion, or in a poultice made from the root, but 
internally it should be prescribed only when the indications for its 
use are present. It is especially useful in the ordinary " caked 
breast," and in badly treated "gathered breasts" with large fistu- 
lous, gaping and angry ulcers, filled with unhealthy granulations 
and discharging a watery, fetid, ichorous pus; the gland is full of 
hard, painful nodosities. 

Silicea. — Chronic mastitis. Long continued suppuration. 
Fistulous openings, with callous edges; discharge thin and watery, 
or thick and offensive. 

Sulphur. — Chronic mastitis, especially in scrofulous subjects. 
Inflammation running in radii from nipple; profuse suppuration, 
with chilliness in the forenoon and heat in the afternoon; old ulcera- 
tions; breasts feel hot; nightsweats, flushes of heat, weak and 
faint spells. 

Mastodynia. 

Synonyms. — Neuralgia of the mammary glands. 

Definition. —A functional disease characterized by attacks 
of pain in one or both breasts, unattended with any symptoms of 
inflammatory disturbance, or evidences of structural changes in 
the glands. Mastodynia may also occur in connection with small, 
hard tumors in the gland, or with lobular indurations, but in such 
cases the neuralgia is secondary to and a result of the changes in 
structure. 

Pathology. — In simple mastodynia no change whatever in 
the structure of the glands can be detected, either by inspection or 
palpation. Billroth maintains that in such instances they are 
probably ' l cases of intercostal neuralgia with radiation to the ante- 
rior part of the thorax." Velpeau, who had a large experience with 
this affection, recognized two other varieties of mastodynia: — 

(1) Tumeurs neuromatiques et nodosities^ and (2) douleurs neu- 
ralgiques et douleurs. The tumeurs neuromatiques consist of hard 



482 A TEXT-BOOK OF GYNECOLOGY. 

nut-sized tumors (neuromata) accompanied by radiating pains, 
which are relieved at once by the removal of the tumors. 

The second variety includes those cases in which the separate 
lobules of the gland are felt with unusual distinctness, sometimes 
as if indurated, accompanied by tormenting pains in the breast, 
which are seldom widely radiated. 

Etiology. — Mastodynia is almost invariably associated with 
some disease or disturbance of the sexual organs. 

Irregularity in menstruation, retroflexion of the uterus, fibroid 
and ovarian tumors, chlorosis, hysteria, and lactation are very 
often accompanied by mammary neuralgia, which is usually aggra- 
vated at or immediately before the menstrual period. It is also apt 
to occur soon after conception, and may continue until full term. 
Sterile women are said to be subject to the disease. 

Symptoms. — The pains are neuralgic in their character, and 
radiate in various directions, sometimes into the axillae, down the 
arm into the back, or down the hips. Vomiting is frequently 
present. Sometimes there are painful spots, which are excessively 
sensitive to touch, on the breast or nipples, and similar spots are 
also sometimes found on the spinous processes of the second, third, 
fourth, fifth and sixth dorsal vertebrae. The left breast is more 
often affected than the right. 

Prognosis. — The disease is never fatal. The prognosis, as 
regards final cure, depends entirely upon our ability to remove 
any constitutional or local causes that may be operating. 

Treatment. — The treatment should be chiefly directed to the 
constitutional conditions present, the indicated remedy being care- 
fully selected and perseveringly administered. During the attack 
hot fomentations or ice-bags may be applied. If the pain is severe 
and these methods do not relieve, chloroform liniment may be 
used, or equal parts of camphor and chloral, thoroughly tritu- 
rated, may be applied. Dr. Julia Holmes Smith recommends 
to spray the breasts with cold water twice a day, and then 
to apply friction until the surface is in a glow. A compression 
bandage is said to afford relief and aid in the cure. Yon Nuss- 
baum has successfully cured a case of neuralgia of the breast 
which had previously resisted all other treatment, by stretching 
the brachial plexus. (1) 

According to Winckel the strict anti-hysterical treatment of 
S. Wier Mitchell, consisting of complete rest associated with a fat- 
tening diet and massage, will prove of great service in the treat- 
ment of this disease. (See page 182.) 



1) Isenschmid, Munchener arztl. Intelligenzblatt, 1883, Bd. XXX, p. 299. 



MASTODYNIA. 483 

Therapeutics. 

Aconite. — Great restlessness and nervous irritation, especially 
in young girls. Pains always aggravated by exposure to cold air. 

Arsenicum. — Agonizing, lancinating pains, always relieved 
by heat and aggravated by cold or cold air; worse after midnight ; 
patient weak and prostrated; great restlessness and anxiety. 

Belladonna. — Especially in plethoric girls; tearing, cutting- 
pains which come and go suddenly; usually worse after 3 p.m. and 
after midnight. 

Chamomilla. — Tearing, drawing pains, accompanied by numb 
sensations in the breast; excessive sensitiveness to pain; nervous 
and irritable. 

Chininum Sulphuricum. — Mastodynia associated with ma- 
laria, or from debility caused by loss of fluids; pains intermittent, 
coming on periodically every other day. Also consult Chininum 
arsenicosum. 

Cimicifuga.— Sharp, lancinating pains in the breasts, asso- 
ciated with ovarian or uterine disturbances; worse on the left side; 
sensitiveness of the spine; hysterical or rheumatic symptoms. 

Cinchona. — Pains excessive; mammae sensitive to touch; after 
sexual excesses or hemorrhages; patient very weak and nervous. 

Ferrum. — Associated with anaemia; fiery redness of face; 
emaciation and weakness; headache before the menses, hysterical 
symptoms after. 

Gelsemium. — Acute, darting, tearing pains along the track 
of the nerves; dvsmenorrhea; trembling and weakness; lano'uid 
and drowsy; easily fatigued. In nervous women, especially girls. 

Ignatia. — Hysterical, nervous patients; constant sighing and 
grieving; jerking and twitching of muscles; over-sensitive to pain; 
great weakness. 

Also consult Argentum nit.. Croton tig., Bryonia, Nuxvom., 
Pulsatilla. Rhus tox. 



CHAPTER LXI. 



TUMORS OF THE MAMMARY GLAND. 

Classification.— Considerable diversity of opinion exists 
among authors as to the correct classification of mammary tumors. 
Undoubtedly the most scientific classification is that which is based 
upon the anatomical structure of the growth. Thus Billroth (1) 
classes fibroma, lipoma, sarcoma, chondroma and osteoma together, 
as consisting of connective tissue proceeding c ' from the cellular 
elements of the connective tissue," and adenoma and carcinoma as 
arising "from the epithelial elements of the glands." 

Gross (2) adopts a combined genetic and anatomical classifi- 
cation. He first divides all mammary tumors into neoplasms and 
cysts; the former being "morbid additions to, or rather over- 
growths of, the component tissues of the organ, and represent an 
excess of normal development and growth." The latter, "with 
the exception of those which surround hydatids, are not new 
formations, but result merely from ectasia or dilatation, and the 
retention of the secretion of the lacteal glands and of their ducts." 

Neoplasms he subdivides into three varieties, as follows : — 

"1. Neoplasms derived from the periglandular connective, 
and constituted by connective tissue or its equivalents, of which 
two divisions may be made, namely :— 

4 ' a. Those which represent perfected or mature connective 
tissue, and may, therefore, be called typical. These comprise 
fibroma, or fibrous tumor, myxoma, or mucous tumor; lipoma, or 
fatty tumor; and chondroma, or cartilaginous tumor. 

"b. The second division includes those neoplasms which 
represent embryonic, unripe, or transitorial connective tissue, and 
may be termed atypical. It is limited to the genus sarcoma. 

"2. Neoplasms which proceed from the secreting elements, 
and are composed of epithelium. Of these, adenoma, or glandu- 
lar tumor, is a typical epithelial growth, while carcinoma is an 
atypical epithelial formation. 

"3. Neoplasms which are derived from and are constituted 
by higher structures. These are, first, angioma, or a tumor com- 
posed of blood-vessels; and secondly, neuroma, or a growth made 
up of nerves." 



1) Diseases of the Female Mammary Glands, p. 41 

2) Tumors of the Mammarv Gland, p. 6. 

484 



TUMORS OF THE MAMMARY GLAND. 485 

While to the pathologist there is much of interest in such a 
classification, which is probably more exact than any other, never- 
theless I am convinced that from a clinical standpoint it is not 
practical, and I shall conform to the simpler plan of dividing 
mammary tumors into (1) Benign; (2) Malignant. These are sub- 
divided as follows :— 

a) 



Bei 
a, 


lign : — 
Fibroma ; 


b. 

c. 


Lipoma ; 

Chondroma and osteoma ; 


d. 


Adenoma and cysto-adenoma ; 


e. 
Ma 


Cysts. 
li tenant \ — 


a. 


Sarcoma; 


b. 


Carcinoma. 



(2) 



BENIGN TUMORS. 

Definition. — This term includes all non-malignant growths, 
whether of connective tissue or epithelial formation. The idea 
that benign tumors do not recur, and basing the classification upon 
that idea, is erroneous, for while true adenoma is benign in its char- 
acter, it is eminently a recurrent growth. 

Until quite recently all benign growths of the breast have 
been known as adenoma, adenocele, or adenoid tumors, and some 
standard text-books still retain these terms; but this is also errone- 
ous, as benign growths include formations which not only differ 
greatly in their origin and nature, but also in their clinical features, 
true adenomata being of the most infrequent occurrence. 

a. Fibroma. 

These are developed from the connective tissue surrounding 
the acini of the mammary gland. They are usually round or oval 
in form, and have a nodular or lobulated outline. They are mod- 
erately vascular, grow very slowly, vary in size from a hazel-nut 
to a heirs-egg, and are usually solitary. Fibromata of the breast 
are rarely homogeneous, but show spaces formed by the dilated, 
elongated and branched excretory ducts of the gland, containing a 
serous, viscid fluid. Under high power the microscope shows that 
the walls are lined by several layers of cylindrical epithelium, and 
that the contents consist of degenerated cells and fine granules 
lying in a clear, homogeneous substance. These tumors are often 
found in virgins and nullipara?; the terminal vesicles forming, 
according to Billroth, a predisposition to cysto-sarcoma. 

This class of growths have been classified by the most eminent 
pathologists as adenoid Or adeno-fibromata, but modern investiga- 
tors describe them as merely fibromata. 



486 A TEXT-BOOK OF GYNECOLOGY. 

Inflammation and suppuration may occur, but it is very un- 
common. According to Gross, (1) "the degenerations of fibromata 
are the cystoid, fatty, myxomatous, osseous, calcareous, and tel- 
angiectatic, but they are infrequent." 

Fibromata are most common between the sixteenth and twen- 
ty-fifth years. They are formed on either side, but rarely occur on 
both sides at the same time. They are usually painless, but not 
always. Gross mentions three examples where "the pain and 
tenderness w T ere so great as to occasion what is known as the irri- 
table tumor of the breast, and in none of these did the growth 
exceed the volume of a small walnut." He considers it highly 
probable that the small growths which excite so much suffering, 
instead of being neuromata, are composed essentially of indurated 
fibrous tissue. Fibromata are said to recur in about one out of 
every sixteen cases, nevertheless they are entirely innocent in their 
nature. As a rule no symptoms are developed, the growth being 
usually accidentally discovered by the patient while washing or 
dressing. 

Cystic fibromata grow more rapidly and acquire a larger size 
than the simple variety. They sometimes grow very slowly for a 
time and then rapidly increase in size, indicating an increase in the 
cystic contents of the growth. Gross says that " in about one case 
out of every seven of cystic fibromata there is a discharge from 
the nipple, but this symptom does not appear to be present in the 
solid form of fibrous tumor." 

Diagnosis. — The diagnosis of fibromata depends chiefly upon 
their indolent nature and insidious origin, their mobility, firm 
consistence, slow growth, moderate dimensions and tabulated 
outline. 

Prognosis. — The prognosis is always favorable unless they 
induce extensive suppuration or exert injurious effects upon neigh- 
boring organs; such instances, however, being of extremely rare 
occurrence. 

Treatment. — The treatment consists in enucleation of the 
tumor, as described in a succeeding chapter. Remedies seem to 
have but little influence upon the growth of this class of tumors, 
but the following may be consulted: Arnica, Baryta carb., Bella- 
donna, Calcarea carb., Calcarea iod., Conium, Iodine, Silicea. 

b. Lipoma. 

Fatty tumors in the breast are of extremely rare occurrence, 
though they not infrequently form behind or near the gland, and 
then, as they grow, push the gland before them. Gross says that 
while examples of fatty tumors, developed in the paramammary 

1) Op. Cit., p. 53. 



TUMORS OF THE MAMMARY GLAND. 487 

adipose tissue, are recorded, he is not aware of a single case of 
circumscribed lipoma occurring in the gland itself. Billroth says 
there is no case known in which the glandular was included in the 
lipomatous tissue. 

After the menopause the glandular tissues atrophy, and the 
whole structure of the breast becomes converted into fatty tissue. 
Fatty degeneration of a fibroma or sarcoma may occur. Para- 




Fig. 201. — Enormous lipoma behind the right mamma (Billroth). 

mammary lipomata give rise to no symptoms except such as result 
from their increased size and weight, though it is claimed that 
they sometimes occasion a burning pain. 

Diagnosis. — The diagnosis is often extremely difficult. Lip- 
oma is most often mistaken for fibroma, but it is more elastic and 
grows more rapidly. 

Treatment. — The treatment consists in extirpation or enu- 
cleation, according to the size of the growth. The following- 
remedies may prove useful: — Baryta carb., Calcarea carb.. Phos- 
phorus, Phytolacca. 

c. Chondroma and Osteoma. 

There is no doubt that cartilaginous and osseous tissue 
may develop in the breast and form a tumor, though such cases 
are exceedingly rare, and those that have been recorded would 
show that such tissues are more apt to exist in connection with 



488 A TEXT-BOOK OF GYNECOLOGY. 

fibromata or sarcomata, small bony or cartilaginous pieces being 
scattered through the other tissues which constitute the greater 
part of the tumor. According to Billroth, the only undoubted 
case of partially ossified chondroma is one that was described by 
Astley Cooper. 

cl. Adenoma. 

True adenoma is a genuine hypertrophy, involving an enlarge- 
ment of epithelial, connective tissue and vascular elements. The 
habit of calling all non-malignant growths in the breast adenomata, 
adenocele, or adenoid, is erroneous, a pure adenoma being one of 
the most uncommon forms of mammary tumor met with. The 
lxypertrophy may be either general or partial, the former being of 
extremely rare occurrence. According to Gross, the physiological 
type of adenoma is to be found in a mamma preparing for lacta- 
tion, and the tumor, which presents a likeness to the mamma of a 
female advanced in gestation, may be styled a typical adenoma. 

The characteristic feature of adenoma is the presence of the 
membrana propria, which separates the investing epithelium from 
the surrounding connective. When it is broken through, and the 
epithelium grows as solid plugs in the stroma, the tumor ceases to 
be an adenoma and becomes a carcinoma. 

Adenomata have a remarkable tendency to become cystic, a 
majority of the cases observed having undergone this transforma- 
tion. Much more rarely does fatty or telangiectatic degeneration 
take place. Spontaneous ulceration has been observed in several 
cases. On section the cut surfaces of an adenoma u are smooth, 
lobed, of a milky-white color, Avith possibly rosaceous areas, and 
dotted with orifices or small cavities, to which, after the expres- 
sion of their contents, is imparted a spongy, honeycomb, or sieve- 
like appearance. Now and then they are occupied by fluid cysts, 
which, however, rarely number more than three or four, are 
usually quite small, and rarely exceed the volume of a walnut. 
They are never pervaded by fissures or slits, nor are they the seat 
of dilated ducts with intra-canalicular solid growths, such as are 
witnessed in the connective tissue neoplasms, or of yellowish lines 
or spots, such as are seen in carcinoma." (1) 

Adenoma is always solitary and, according to Gross, usually 
originates toward the upper and inner circumference of the mam- 
ma, rarely beneath or in the vicinity of the nipple. Its growth 
is slower than other tumors of the breast, and is not caused or 
inflamed by lactation, pregnancy, menstrual disorders or uterine 
affections. 

Adenoma is usually ovoid, and regularly but not permanently 

1) Gross, Op. Cit., p. 119. 



TUMORS OF THE MAMMARY GLAND, 489 

nodulated, and of hard consistence, except where cystic degenera- 
tion has taken place. 

Diagnosis. — According to Billroth, "the differentiation of 
adenoma from many other tumors of the breast is usually difficult." 
If the growth is small, it is most apt to be confounded with 
fibroma, but the latter is more circumscribed and mobile, and is 
more easily isolated. The diagnosis is for the most part based 
upon the firm consistence of the tumor, its regular but not promi- 
nent nodulations, its mobility and its slow growth. From carci- 
noma it can usually be distinguished by an absence of the fol- 
lowing features of that disease: — pain, retraction of the nipple, 
enlargement of the subcutaneous veins and involvement of the 
lymphatics. 

Prognosis. — An adenoma does not affect the general health 
or involve other organs, thus showing its benign character; though 
in about one half the cases recorded the tumor has recurred after 
extirpation. 

Treatment. — That such tumors are amenable to treatment 
there can be no doubt. I believe a majority of cases can be cured 
without surgical interference. I have had but two cases of true 
adenoma, both of which were cured with Phytolacca. Dr. Hel- 
muth recommends for adenomata in general Calcarea carb., Conium 
and, especially. Phosphorus. I would suggest also : — Baryta carb. , 
Iodine, Silicea and Sulphur, and for cysto-adenomata. Apis and 
Arsenicum. 

The surgical treatment consists in enucleation or extirpation, 
though in some instances where the growth is large and involving 
the greater part or all of the gland, amputation may be preferable. 
(See Chapter LXIV.) 

Diffuse Hypertrophy of Both Breasts.— Of this rare con- 
dition I will make but brief mention. Billroth has seen only two 
cases, the illustrations of which I reproduce (Figs. 202, 203). I 
have seen one case in a maiden lady sixty-five years of age. In 
this case the hypertrophy began at puberty, which did not occur 
until the seventeenth year, after which the development continued 
steadily for about three years. Since that time the growth has 
remained stationary, the patient suffering only from the discom- 
fort of the increased weight of the breasts and the inconvenience 
caused by wearing such clothing as has been necessary to support 
them. The condition occurs usually at the beginning of menstrua- 
tion, or soon after. The breasts are not usually of the same size, 
one being more hypertrophied than the other. The nipple is flat 
or umbilicated, the skin appears thickened or cedematous, and the 
subcutaneous veins are greatly enlarged. The development is 
always rapid for two or three months, and then the enlarged 



490 



A TEXT-BOOK OF GYNECOLOGY. 



breasts remain stationary. Billroth says that "there is no such 
thing as a continuous and indefinite growth of it." 

There is very little or no pain in the breasts, and no constitu- 




Fig. 202.— Hypertrophy of both breasts. Girl 16 years old (Billroth). 
tional disturbance except when the great weight of the breasts 
prevent the patient from attending to her usual duties, thus inter- 
fering with her nutrition. 



TUMORS OF THE MAMMARY GLAND. 



491 




Fig. 203.— Hypertrophy of the breasts. Woman 22 years old (Billroth). 



492 A TEXT-BOOK OF GYNECOLOGY. 

When the breasts become a burden on account of their size, 
bi-lateral amputation is the only means of affording perfect relief. 

e. Cysts. 

Pure cysts, distinct from adenoma or sarcoma, are of rare 
occurrence. They seldom become larger than an orange, are of 
slow growth, and usually occur after the fortieth year. These 
are simple retaining cysts, but do not include the milk cyst, or 
galactocele, which arises during lactation from dilatation of the 




Fig. 204. — Mamma with many small cysts; prepared with a portion of the 
skin, the nipple and areola (Astley Cooper). 

sinuses and larger ducts, nor do they include the hydatid cyst, 
which is occasionally found in the mammary gland. 

According to Billroth, the simple mammary cysts are invari- 
ably developed from dilatation of the small excretory ducts, and 
remnants of the division walls may be distinctly seen in the larger 
cysts. The inner surface is undulating, and occasionally shows 
papillary excrescence; some traces of epithelium may be seen in 
the larger cysts. The contents are thin or viscid, and greenish or 



TUMORS OF THE MAMMARY GLAND. 



493 



brownish. Microscopical examination shows the presence of gran- 
ular cells, translucent, globular bodies, hematoidin, cholesterine 
and fat crystals. The pigment is often an intense biliary green. 
The browmish color is probably produced by thrombosis of the 
vessels or hemorrhage from the exceedingly vascular cyst walls. 
Calcification may take place in the latter, and then the contents 
are colorless, yellowish or white. 

Another form of cyst occasionally found in the mammae con- 
tains a substance resembling oil (TTormald, Gross), cream, butter 
(Velpeau) or mortar. According to the investigations of H. Klotz, 




Fig. 205. — Compound cystoma. Natural size (Velpeau). 



these consist of saponified fat, and, in his opinion, this abnormal 
secretion, as well as the normal secretion, depends upon the influ- 
ence of the secretory nerves. 

The origin of these cysts has no connection whatever with 
pregnancy or lactation. 

Diagnosis. — The diagnosis of a mammary cyst is exceedingly 
difficult, as its firm consistence, mobility, and painless, chronic 
course render it very liable to be confounded with a solid tumor. 
If multiple cysts are present, their hard, irregular feel may 
simulate carcinoma, but they do not give rise to pain or any con- 
stitutional disturbance. 

The use of an aspirator or exploring needle will generally 



494 A TEXT-BOOK OF GYNECOLOGY. 

establish the eystic nature of the growth and should be resorted to 
before an opinion is given. 

Prognosis. — The prognosis is always favorable. 

Treatment. — It is probable that cysts of the mammary 
gland may sometimes be removed by medicines, but as their extir- 
pation is not attended with danger it is doubtless best to remove 
them at once, especially as there is always a possibility of an error 
in diagnosis. 



CHAPTER LXII. 

MALIGNANT TUMORS OF THE MAMMARY GLAND. 

Sarcoma. 

Varieties. — Sarcoma of the mammary gland may be either 
round-celled. , spindle-celled, or giant-celled. 

The varieties are determined by the prevailing form of the 
cells. They may also be either soft or hard, according to the 
nature and extent of the intercellular substance, which, according 
to its relative amount and distribution, renders necessary a sub- 
division of the varieties named into hyaline, granular, fibrillated, 
lymphoid and alveolar. Also, by various transformations, sar- 
coma may become myxomatous, fatty, telangiectatic, cystoid and 
calcareous. I shall not attempt a separate consideration of sar- 
coma in all these varieties and subdivisions. In the first place, the 
original varieties named do not differ from those of sarcoma as 
occurring elsewhere, and do not require special consideration at 
this time, while many of the sub-varieties mentioned have never 
been observed in the mammary gland. I shall, therefore, be con- 
tent with a brief mention of such varieties as arc most often 
observed in this location, including the so-called proliferating 
cysto-sarcoma. which is a distinct and peculiar variety, and of com- 
paratively frequent occurrence. 

Billroth has never met with cases of spindle-celled sarcoma, 
myxo-sarcoma. or plexiform-sarcoma in the breast, although spin- 
dle cells and myxomatous tissue were occasionally observed in 
portions of proliferating cysto-sarcomata. 

Hard Sarcoma. — This is the fibrosarcoma of Billroth, the 
intercellular spaces being filled with fibrous tissue which imparts 
a hard, firm consistence. Such tumors are most often spindle- 
celled, sometimes round-celled, are nodular, richly supplied with 
blood-vessels, compact, loosely adherent to the gland, and tough 
on section. It is a peculiarity of the hard sarcoma that its tissue 
remains the same, no matter how long they have existed, though, 
according to Billroth, there may eventually be a transition to 
cysto-sarcoma. 

These tumors give rise to no pain, and are not sensitive except 
in rare cases, when the}' are adherent to nerves. TThen first 
noticed they are usually from the size of a hazel-nut to that of a 

495 



496 A TEXT-BOOK OF GYNECOLOGY. 

walnut, and are most often found between the sixteenth and the 
twenty-fifth year of age, never occurring before puberty or after 
the menopause. They are of very slow growth, and may 
exist in an apparently unchanged condition for an indefinite period, 
even for many years. That such tumors, after remaining sta- 
tionary and painless for years, become changed into carcinoma, is 
credited by Billroth. Many of the growths termed adenoid belong- 
to this variety. Their differentiation from simple fibroma without 
the aid of the microscope is practically impossible. 

Soft Sarcoma. — The soft, or medullary sarcoma, according 
to Billroth, seldom occurs in the breast. They are usually round- 
celled, sometimes spindle-celled, and appear as soft, elastic, mov- 
able, encapsulated tumors. In some instances they will be found to 
be composed of small, fusiform cells, or to have undergone myx- 
omatous or fatty degeneration, or to be the seat of interstitial 
hemorrhages. In the latter case the soft, brain-like tissue may 
become so extensively interspersed with clots of blood, or with 
cysts containing blood, that the term hematoid sarcoma is applied 
to them, or fungus hematodes if they protrude through the skin. 
They usually appear in one gland only, but may be present in both 
glands at the same time. They grow slowly at first, but more 
rapidly during the second year; they are not very painful; the 
axillary glands are not invariably enlarged. Recurrence happens 
soon after extirpation, death occurring in from one to four years, 
with secondary growths, from metastasis in the lungs and liver. 

The diagnosis of soft sarcoma is much easier than that of the 
fibrous variety. According to Gross (1), a tumor "of soft, elastic 
appearance and fluctuating consistence, which attains the volume 
of an adult head in a few months, can scarcely be anything else 
than a small-celled sarcoma. On the whole, the diagnosis is based 
upon their indolent origin, mobility, central situation, elastic, or 
unequal consistence, lobulated outline, rapid increase, large dimen- 
sions for the period of their existence, freedom from lymphatic 
involvement, their marked tendency to ulcerate, the not infrequent 
discoloration of the skin and enlargement of the subcutaneous 
veins, and, possibly, elevation of temperature; upon the suffering 
which they awaken late in the disease ; and upon their greatest fre- 
quency after the thirty-fifth year." 

Osteoid Sarcoma. — This is a new variety of sarcoma recently 
described by Stilling, whose investigations are recorded by Winckel 
(2) ' c In three cases he found a tumor arising without apparent 
cause, the patients being parous women over fifty years of age. 
They began as isolated tumors, which displaced the tissue of the 



1) Op. Cit., p. 89. 

2) Op. Cit., p. 641. 



MALIGNANT MAMMARY TUMORS. 497 

gland as they grew, and remained solitary. Their malignancy was 
apparent from the extension of the tumor to the subcutaneous 
tissue, from its rapid growth, quick recurrence, and the develop- 
ment of metastatic tumors in distant organs. Microscopically, the 
tumor consisted of a network of osteoid strands filled with cellular 
elements. The osteoid substance showed the configuration of true 
osseous tissue ; the hyaline striated matrix contained alveoli often 
having prolongations in which globular cells were formed. The 
central portions of the osteoid tissue had become calcified, and had 
non-petrified tissue on each side ; from the latter there were pro- 
longations sent out into the network, forming a kind of reticulated 
tissue about the cells. The cells between the strands of osteoid 
tissue were fusiform, round or polygonal in shape and of variable 
size, some of them strongly resembling cartilage corpuscles. The 
metastatic tumors were similar in composition to the recent portion 
of the primary tumor. The osteoid strands were only partially 
calcified ; there was a limited quantity of cartilage, and many ele- 
ments resembling cartilage corpuscles. Stilling says the cases of 
Bonet and Heurtaux were of this character, and thinks that the 
same is probably true of those of giant-celled sarcoma described 
by Robin, Lancereaux, Paget and Billroth." 

Proliferating Cysto-Sarcoma. — This is the term given by 
Mtlller to a peculiar sarcomatous growth, which Virchow desig- 
nated as " intra-canalicular myxoma," and which by others has been 
known by various terms, such as "sero-cystic sarcoma," "glandu- 
lar proliferous cysts," "cellular hydatids," "tumeurs adenoides," 
etc. 

Proliferating cysto-sarcoma is an encapsulated, nodulated 
tumor of variable consistence, reddish-gray or pale on section, often 
gelatinous and cedematous, and containing' extravasations. 

This form of sarcoma can occur only in the mamma, as it 
always includes granular elements found nowhere else. The anat- 
omy is thus described by Winckel (1) : — 

"There are irregular spaces filled with a thin mucus, into 
which the polypoid and leaf -shaped proliferations project. Near 
these are found numerous branched and a few rounded cystic 
cavities. 

"The cysto-sarcoma nodules are a proliferation of the layer of 
hyaline connective tissue which surrounds the acini. As the space 
is increased the epithelium of the acini is correspondingly multi- 
plied, the acini being drawn out into narrow canals and the ducts 
dilated. The epithelium of the acini becomes stratified, and of a 
cylindrical character on the surface ; tubercles are formed by the 
aggregation of the epithelial cells, or they may dissolve into a 



1) Op. Cit., p. 642. 



498 



A TEXT-BOOK OF GYNECOLOGY. 



homogeneous mucus which fills and distends the canals. The 
structure is composed of a somewhat cedematous connective tissue, 
arranged in fasiculi and rich in cells ; it is partially myxomatous 
or lymphoid, but it rarely contains spindle-cells." 




Fig. 206. — Section of a proliferous cysto-sarcoma of the breast. One third 
natural life (Billroth). 

According to Billroth the prognostic significance of proliferat- 
ing cysto-sarcoma ' ' depends not on the contents and mass of the 
cysts, but on the histological character of the interstitial tissues, 




Fig. 207. — Enormous cysto-sarcoma of the mamma (Velpeau). 



which always possess sufficient peculiarities to separate them from 
fibro-sarcomata, soft sarcoma and adenoma ; though it must be 



MALIGNANT MAMMARY TUMORS. 



499 



remembered that these forms of tumors are not to be sharply dif- 
erentiated anatomically, and there may be many combinations 
of them." 

This variety of sarcoma originates most often between the 
thirtieth and fortieth years of life, and in the married and parous 
rather than in the unmarried and sterile. An important diagnostic 
feature is that they are always movable in the gland, never adher- 
ent to the thorax, even when they grow to giant' size, which they 




Fig. 208. — Myxomatous 

sarcoma. 



and telangiectatic cystic small spindle-celled 



sometimes do. Their growth is variable, sometimes being very 
slow and at other times very rapid. They are usually painless, 
and not sensitive to touch or light pressure. They sometimes 
attain an enormous size. Velpeau reports a case (Fig. 207) 14.4 
inches in vertical diameter, twelve inches transversely and forty- 
eight inches in circumference. Billroth believes that these tumors 
sometimes arise from fibro-sarcomata of long standing. 

There is always a tendency to recurrence after removal. Bill- 
roth operated upon nineteen cases, of which twelve remained free 



500 A TEXT BOOK OF GYNECOLOGY. 

from recurrence from two to ten years after. Local recurrences 
may take place, owing to the fact that the tumor alone is removed, 
and not the whole gland. Billroth operated upon one woman five 
times in four years, there being quick recurrence. After the whole 
gland was removed there had been no recurrence in three years. 

Cysto-sarcoma is seldom infectious, though Billroth reports 
cases where metastasis to internal organs took place, but without 
infection of the lymphatic glands. 

Prognosis of Sarcoma. — Gross (1) gives some important 
points on the prognosis of sarcoma, based upon a study of sixty 
cases. He concludes that " Round-celled tumors, whether solid or 
cystic, or whether they pursue a natural course or be subjected to 
operation, are excessively malignant, 51 and that the prognosis of 
spindle-celled sarcoma is scarcely more favorable. Contrary to 
the idea that sarcoma is not infectious, and that recurrences are 
less frequent after the removal of the whole gland, Gross remarks 
that it is " interesting to note that recurrence was met with just 
as frequently after the entire removal of the breast as after partial 
operations, and that it was certainly due to local infection in all 
except possibly one, in which multiplicity of the original growth 
may have denoted the further development of nodules which es- 
caped observation at the first enucleation. 

" Sarcoma recurs less frequently and not so rapidly as carci- 
noma ; it is more liable /to visceral complications than is the latter." 

It is "less infectious locally, but more infectious as regards 
the general system, than carcinoma. Its more relatively benign 
character is, moreover, shown by the fact that the average duration 
of life, from the first observation of the disease to the date of the 
last report after removal, is seven years, against thirty-seven 
months for carcinoma; and this contrast becomes the more striking 
when it is stated that the majority of the sarcomatous patients 
were still living, while the majority of the carcinomatous subjects 
were dead. Not only is this statement true for all sarcomata, but 
it holds good for the two principal varieties, since the average life 
for the round-celled sarcoma is four years, and seven years and a 
half for the spindle-celled. 

"Although the recurrent regional disease is more intense than 
the primary, and other reproductions generally follow in quick 
succession, there can be no doubt that the removal of the tumors, 
as fast as they appear, alleviates suffering, prolongs life, and averts 
visceral contamination. 

"The prognosis is materially influenced by the age of the 
patient and by the size and rate of increase of the tumor. Thus 
in young persons, or before the age of thirty-five, when the gland 

1) Op. Cit., p. 90. 



MALIGNANT MAMMARY TUMORS. 501 

is functionally most active, a small, slowly growing sarcoma does 
not return, while a rapidly increasing cystic tumor is very liable 
to recur. 

••The prognosis is also influenced by the histological constitu- 
tion of the tumor and the stage of its evolution. Of the spindle- 
celled 56.25 per cent, recurred, and 18.75 per cent, gave rise to 
metastatic growths; of the round-celled 70 per cent, recurred and 
30 per cent, were generalized; of the cystic 53. 3 per cent, recurred 
and 13.3 per cent, were disseminated; while, of the solid, 55.5 
per cent, recurred, and 22.2 were generalized. Hence, while the 
round-celled are to be regarded as the most pernicious, the metas- 
tasis of the spindle-celled is by no means to be denied; nor can 
one say, with Erichsen, that the cystic variety tends to wear itself 
out by repeated operations, since it recurs almost as frequently as 
the solid variety, although the latter reproduces itself in distant 
parts in 9 per cent, more of the cases. These investigations dem- 
onstrate that the usual statements, which are so opposed to the 
actual facts as to the malignity of sarcomata, are due either to their 
not having been based upon a careful analysis of recorded cases, 
continued by minute examination, or to the confounding of cystic 
sarcomata with cystic fibromata, which never infect the economy." 
Treatment of Sarcoma. — Very little has yet been accom- 
plished in the treatment of sarcoma with medicines. Doubtless 
some benefit may be derived from the persistent use of the care- 
fully selected remedy, but no authentic and reliable reports of 
cases cured, or even materially benefited, have come under my 
observation. Helmuth reports (1) a very interesting case of cysto- 
.sarcoma of the breast, in which, after giving • • many medicines, 
among others Calcarea, Silicea, Kali, Iodine, Nux, Sulphur, etc.,'' 
without much benefit, he prescribed Kali bromatum, two grains 
three times daily for two weeks, when "two of the larger cysts 
opened, and the amount of discharge that passed away was so large 
and so long continued as to utterly surprise all Avho beheld it. 
Three smaller cysts, which lay beyond the internal margin of the 
gland disappeared; one on the apex of the shoulder also disappeared, 
and the balance of the tumor shrunk perceptibly. The medicine 
was still continued, lessening the dose, however, when two other 
large cysts at the inferior surface of the tumor gave way and freely 
discharged. After the evacuation of the liquid, in the bottom of 
cavities were large masses of decomposed substance resembling 
the cores of decayed apples or of bulbous vegetation. This I 
scraped away in large quantities, the tumor, meanwhile, growing 
smaller, but the patient evidently very much weaker. The decayed 
masses which were removed were very fetid, and it was only by 

1) System of Surgery. 5th ed\. p. 19s. 



502 A TEXT-BOOK OF GYNECOLOGY. 

the use of constant injections of carbolic acid, and the application 
of disinfectants, with careful attention to proper ventilation and 
cleanliness, that she could be kept at all comfortable. She had 
from time to time many symptoms that would indicate the occur- 
rence of paralysis of the affected side, but these would gradually 
subside." 

He then remarks the patient died, bat that the case is 
k ' recorded not only from the rarity of its nature, but to mark the 
action of the bromide of potash. 

' ' Whether the rupturing of some of the cysts and the disap- 
pearance of others were merely coincidences occurring after the 
bromide had been given, or whether it was the true action of this 
important medicinal agents I am at a loss to determine, although 
I am disposed to place the changes which took place in the morbid , 
mass to the action of the medicine, and I think I may do this 
with some confidence, when it is remembered what peculiar action 
this medicine has been known to possess in other forms of cystic 
disease." 

There is probably no question but that sarcomatous tumors 
should be removed either by enucleation or amputation of the 
whole breast (see Chapter LXIV), according to the size of the 
growth, just as soon as the real nature of the disease is ascertained. 
Should it subsequently appear that the growth was either benign 
or carcinomatous, the operation is none the less indicated, even 
though in the former case it might not have been absolutely 
necessary. 



CHAPTEK LXIIL 



CARCINOMA OF THE MAMMARY GLAND. 

Varieties. — The varied and conflicting classifications of mam- 
mary carcinoma based upon supposed histological or pathological 
features must necessarily prove bewildering to the student, I shall, 
therefore, follow the plan adopted in treating of carcinoma of the 
uterus, and classify carcinoma of the breast as (1) Scirrhous, or 
hard cancer; (2) medullary or encephaloid, or soft cancer; (3) epi- 
thelioma, or cancroid, and (4) colloid cancer, the last named not 
having been considered in connection with carcinoma of the uterus. 
The chief histological features of these varieties do not vary essen- 
tially from those already described in Chapter XXXIII, and need 
not be repeated. I will only mention such features and sab- 
varieties as are characteristic of mammary carcinoma, and which 
have not already been mentioned in the chapter to which reference 
has been made. 

(1) Scirrhous, or hard cancer. — This variety corresponds to 
the fibrous or connective-tissue carcinoma of some authors, and 
the tubular form of Billroth. It includes not only the ordinary 
scirrhus, but also the simple carcinoma of Billroth, and the atro- 
phying, retracting, withering, or cicatrizing carcinoma of Velpeau, 
Gross and others. Scirrhus is the most frequent form of mam- 
mary cancer. 

Simple carcinoma, termed fibroso-meclullary by Waldeyer, 
occupies a position between ordinary scirrhus and encephaloma. 
The cells and stroma exist in about equal proportions. 

Atrophying scirrhus is peculiar to the mammary gland. In 
this form, according to Gross (1), " the epithelial elements undergo 
fatty degeneration, whereby they are partly converted into a 
granular emulsion, which is absorbed, while the contracting stroma 
renders the alveoli smaller and narrower, so that they are merely 
represented by a few elongated or fusiform clefts, between the 
thick tendinous or sclerosed bands of fibrous tissue, which contain 
fatty detritus, or one or more rows of unchanged cells. 

"It creaks under the knife; and its cut surfaces are deeply 
concave, of a tendinous, glistening, bluish-gray lustre, and dotted 
here and there with pale yellow granular spots. The juice, if 
any at all can be expressed, is of a thin and citron-colored serous 
nature." 



1) Op. Cit., p. 131. 503 



504 



A TEXT-BOOK OF GYNECOLOGY. 



(2) Medullary, or Encephaloid. — This variety is termed 
acinous carcinoma by Billroth, and multicellular carcinoma by 
Gross. It stands next in frequency to scirrhus in mammary car- 
cinoma. The pathological features of medullary cancer are suffi- 
ciently given on page 281. 

(3) Epithelioma. — Epithelial cancer of the breast is of very 
rare occurrence, and is not mentioned by either Billroth or Gross. 
Prof. Hall, of Chicago, has seen three cases. 

(4) Colloid Carcinoma. — This form is also known as gela- 




Fig. 209.— Atrophying scirrhus of the right mammary gland. 

tinous carcinoma, and is of rare occurrence. There exists a differ- 
ence among pathologists as to the real nature of colloid carcinoma. 
Klebs and Billroth maintain that the collqid matter is derived from 
the epithelial cells. Doutrelepont claims that it is exuded from 
the vessels. Rindfleisch seems to hold the same idea. Gross and 
others hold that it results from a colloid degeneration of the pro- 
toplasm of the cells of ordinary cancer. Simmonds recognizes all 



CARCINOMA OF THE MAMMARY GLANDS. 505 

these views as possibly correct. Winckel (1) thus describes the 
anatomy of a colloid growth as taken from a record of twenty 
cases by Simmonds: — 

u The nodule may be as large as a walnut, the fist, or even 
larger, have inequalities upon its surface, and present upon section 
a honeycomb appearance. The cavities contain epithelial cells, 
collected in round masses, and surrounded by a translucent homo- 
geneous layer of colloid substance, which is separated from the 
connective-tissue stroma by a well-defined boundary line. The 
small-celled infiltration is very irregularly distributed, being uni- 
form only at the borders; in some places the epithelium has under- 
gone fatty degeneration; contraction apparently never occurs, 
probably because the colloid substance is absorbed with such 
difficulty. " 

Pathology and Clinical Course of Mammary Carcinoma. 
— Ordinary scirrhus of the breast presents a rounded, irregular, 
nodular outline, and is frequently depressed or cup-shaped on the 
surface. It is very hard and unyielding, and is, proportionately 
to its size — being usually no larger than a hen's egg — heavier than 
any other mammary tumor. 

Simple carcinoma presents a firm but not decidedly hard con- 
sistence, is bossed rather than nodulated, somewhat regular in out- 
line, and grows considerably larger than true scirrhus. Not infre- 
quently areas of caseation, softening and increased vascularity are 
present, and cancer juice may be expressed, though not to the 
same extent as in the medullary variety. 

Atrophying scirrhus is the smallest of all varieties of carci- 
noma of the breast, and is also the most dense and inflexibly hard. 

Medullary carcinoma is of a soft, elastic consistence, yielding 
almost a fluctuating feel. It attains greater dimensions than any 
variety of scirrhus. It presents many features in common with 
soft sarcoma, its contents often resembling brain tissue, and when 
this contains spaces filled with blood it is sometimes termed hema- 
toid cancer, or fungous nematodes, from the sarcomatous variety of 
which it is impossible to distinguish it without the aid of the 
microscope. 

Epithelioma is superficial, beginning on the cutaneous surf ace 
near the nipple, and may extend along the epithelial lining of the 
lactiferous ducts, or spread along the integument of the areola. 
In its progress it destroys the tissues from without inward, there 
being no distinct tumor. It may, however, give rise to small, 
nodular growths beneath its surface, and to diffuse thickening of 
the ,skin about the area of ulceration. Although epithelioma begins 
earlier, its progress is slower and less painful than in either of the 

1) Op. Cit, p. 647. 



506 A TEXT-BOOK OF GYNECOLOGY. 

forms of cancer just given, which attack the deeper structures of 
the gland. If not extirpated, the entire gland may be infiltrated, 
metastasis occur, and death follow from general exhaustion. 

Colloid carcinoma is very nearly as hard as ordinary scirrhus 
and the growth is about the same size. All forms of carcinoma 
tend to involve only a single lobe of the breast, although, excep- 
tionally, several lobes may be involved, and, very rarely, the whole 
gland. According to Billroth, it cannot be positively stated wheth- 
er infiltration of the connective tissue, or epithelial proliferation, 
constitutes the initial process, but the skin is first involved, then 
the retro-mammary fascia, and, lastly, the pectoralis major muscle. 

u This extension does not take place, by any means, to an equal 
degree in all directions, but frequently in the form of cords which 
radiate from the carcinomatous focus into the adjacent tissue, and, 
far more frequently, interruptedly, in the form of nodules, which 
appear around the carcinoma as a papular exanthem, constantly 
spreading in wider circles around the primary focus; between 
these parts the tissues may remain entirely healthy for along time, 
until finally, if life lasts, the nodules grow into a large, confluent, 
nodular tumor. When we see this condition on the skin, we can, 
as a rule, conclude that a like .condition exists in the deeper cel- 
lular tissue and in the muscle." 

After the pectoral muscles have become affected, the disease 
soon extends to the periosteum, the ribs, the costal pleura, and, 
finally, to the pleura covering the lungs. 

The lymphatic glands of the axillae become involved in about 
sixteen months from the first appearance of the disease. Billroth 
claims that the tissue in these glands is carcinomatous, but Gross 
maintains that it is not always carcinomatous, as several cases 
are on record in which it has been left behind during opera- 
tions, and afterward subsided; the patients being alive years after- 
ward. If, however, the same tissue-changes occur in the 
axilla? as in the primary cancer, it is probable that the cancer cells 
have been transmitted to various parts of the body by the veins 
and lymphatics. Billroth states that he has repeatedly seen the 
lymphatic systems of the pleura and diaphragm completely filled 
with carcinoma-cells, and he considers it, in the present state of 
our knowledge, highly probable that the continued, as well as 
the interrupted, extension of carcinoma is brought about by 
misplacement of corpuscular elements. It is now well established 
that when an operation is performed before the glands have become 
perceptibly involved, the patient will survive for a much longer 
period; even when recurrence takes place, the operation not only 
prolongs life by lengthening their intervals, but may even effect a 
permanent cure. 



CARCINOMA OF THE MAMMARY GLAND. 507 

The large, soft nodules of medullary carcinoma run the most 
rapid course, this being from six months to one year, while the 
scirrhous variety is much slower, lasting from two to six years, and 
sometimes much longer. 

In Doutrelepont's case of colloid cancer the disease lasted 
thirteen years. According to Simmonds, gelatinous cancer grows 
more slowly than any other form; the axillary glands are less fre- 
quently involved; metastases occur later; recurrences are more 
rare, and it is, therefore, of a more benign nature than any of the 

m 




Fig. 210. — Local dissemination and superficial ulceration of scirrhus. 

other varieties. The atrophic, cicatrizing variety of cancer may 
continue more than twenty years. 

Metastasis to parts where continuity of the disease would be 
impossible, occurs on an average in about two years. Metastatic 
deposits are found more frequently in the liver than in the lungs, 
and finally in the bones and brain. Billroth has not infrequently 
observed later invasion of the second mamma, as have several 
other authors. Superficial or deeply-seated ulceration may take 
place, involving only the integument, or the substance of the tumor 



508 



A TEXT-BOOK OF GYNECOLOGY. 



itself, from fatty and disintegrating changes. Superficial ulcera- 
tion is represented in Fig. 210. In these cases, according to 
Gross, u the thin and discolored skin is at first cracked, fissured, 
excoriated, or eroded, and covered by thin crusts. Ere long a 
sore forms, which has a pale, granulating base, and discharges a 
thin, offensive fluid. Now and then it heals over, the cicatrix being- 
thin, tense, red, and traversed by small vessels; or healing occurs 
in the first breach of continuity, while the ulceration continues to 
spread.-' 




Fig. 211 —Local dissemination and deep ulceration of scirrhous carcinoma. 



If the ulceration be deep-seated (Fig. 21-1), tl adeep, exca- 
vated or crater-like cavity, with irregular, discolored, full, indu- 
rated and everted edges, and a base which is usually formed of 
hard granulations, and which discharges a puriform, bloody, foul, 
or ichorous fluid. " 

Billroth speaks of agaric-like (fungous) growths being charac- 
teristic of medullary carcinoma, yet Gross maintains that c ' although 
carcinoma is said to throw out fungous masses, I fancy that the 
statement is traditional, and I cannot find a single example con- 
firmed by minute examination." Though the secretion of such 



CARCINOMA OF THE MAMMARY GLAND. 509 

ulcers consists in part of true pus, yet there is seldom a formation 
of a really acute or chronic abscess in mammary carcinoma. 

Ulceration may occur as early as the ninth month, but usually 
it is from the fifteenth to the thirtieth. 

Adhesion to the skin usually takes place about six months 
prior to the ulcerative process, but adhesion to the chest does not 
occur until some two or three months after, generally about the 
twentieth month after the invasion of the disease. This process 
depends upon the extension of the disease to the retro-mammary 
fascia, and the pectoral muscles, and does not occur until that has 
taken place. At the same time it also usually marks the lymphatic 
involvement, the latter being understood to exist, even though it 
cannot be detected, whenever fixation of the tumor has occurred. 
Recurrences take place, according to Billroth, either by continuity 
at the site of the operation, due to portions of the tumor being 
left behind (either intentionally or otherwise) ; by regional disease ; 
by new tumors springing up independently of the original tumor ; 
bv infection, neighboring glands having; been involved before the 
operation ; or by metastases, such as have already been mentioned. 

According to Winiwarter's statistics, recurrence takes place 
within the first three months after operation in 82.4 per cent, of 
all cases. Billroth states that when an experienced surgeon is un- 
able to detect recurrence one year after the wound made by the 
operation has healed, the patient may be considered as radically 
cured. He has fifteen cases in which patients were free from 
recurrence of the disease for thirteen months to twelve years after 
the operation. 

I think the position of Valkmann is the safest. He says : 
' * If a whole year passes after the operation, without a local recur- 
rence, glandular swelling or symptom of internal affection being 
demonstrated on most careful examination, we may begin to hope 
that a permanent, good result has been obtained, of which we are 
usually certain after two years, and, almost without exception, 
positive of after three years." 

Gross says ' ; a radical cure may be assumed if the patient has 
survived the disease over three years without local or general 
recurrence after the last operation, or if she has died of some in- 
tercurrent malady under the same conditions." 

According to Billroth we can set no limit to regional recur- 
rences, which have taken place as long as twenty years after an 
operation. 

From the statistics prepared by several eminent observers it 
is quite certain that a removal of the growth will retard the dis- 
ease, adding an average of at least twelve months to the life of the 
patient. Not only is the life of the patient prolonged, but statis- 



510 A TEXT-BOOK OF GYNECOLOGY. 

tics show that thorough operations result in permanent recovery 
in over nine per cent, of all cases. Atrophying scirrhus is the most 
pernicious of all the forms of carcinoma. Patients having it may 
live for a long time, even twenty or thirty years, but they always 
die sooner or later from its effects. After operation the disease 
invariably recurs, and metastatic deposits have been found in every 
case where a post-mortem examination has been made. 

Carcinoma of the breast rarely occurs before the thirtieth 
year of age. After that age it gradually increases, reaching its 
maximum of frequency at forty-eight, and then decreasing, rarely 
occurs after the age of seventy. 

Etiology. — Very little is really known as to the etiology of 
mammary carcinoma. That it may arise from either constitutional 
or local causes is quite probable. Heredity does not exert so im- 
portant an influence as some have supposed, only about eight per 
cent, of the cases showing any hereditary predisposition. 

A depreciated general health has little or no influence in the 
production of the disease, quite a large proportion of the women 
in whom carcinomata have developed having been in robust, or in 
fairly good health, and only a very small number showing any 
evidences of a dyscrasia or enfeebled constitution. 

The puerperal process is considered to exert a prominent pre- 
disposing influence. I think, however, that the reason that a large 
proportion of cases occur in the married is more from the fact 
that, as has already been noted, the disease is most liable to occur 
at a period in life when most women either are or have been mar- 
ried, and that the relations of the married state have no direct 
influence in the production of the disease. A small percentage of 
cases have originated during pregnancy, but there is no evidence 
that these cases might not have occurred had the women not been 
pregnant. It is probable, however, that if a carcinoma of the 
breast has already started, it will be hastened in its growth by the 
irritation of the breasts which accompanies pregnancy. Sterility is 
considered a predisposing cause, notwithstanding the fact that car- 
cinoma of the breast has occurred in a much larger number of 
multiparous than nulliparous women. 

That former attacks of puerperal mastitis predispose to car- 
cinoma there can be no doubt, more than eight per cent, of the 
cases being supposedly traceable to this cause. Winiwarter claims 
a proportion of twenty-one per cent. , but, as Winckel says, ' < this 
relationship would be the more clearly marked if it could be 
shown that carcinoma appears in the portion of the gland which 
had been inflamed." Notwithstanding these opinions, I think it is 
safe to ascribe at least a small proportion of cases to lumps and 



CARCINOMA OF THE MAMMARY GLAND. 511 

chronic indurations left by puerperal mastitis, which, after an inde- 
finite period, become carcinomatous. 

Mechanical injury, such as blows and contusions, are supposed 
to have been the cause in about eleven per cent, of the cases. 
Prof. Hall (1) suggests that u it is difficult to determine the exact 
influence which injury may hold in the production of those changes 
which result in cancer. In many cases the injury is so remote 
from the development that the patient forgets the occurrence. It 
is not infrequent, however, to have such a history related. A 
woman, forty -six years of age, previously healthy, struck her 
breast against the bedpost, causing severe pain. The indications 
of a tumor developed rapidly, but so acute w T ere the symptoms 
that it was supposed to be merely an inflammatory condition. In 
six weeks it had involved the whole gland, and was removed. Six 
months later the patient died from recurrent growths. From one 
hundred cases coming under my own observation, twenty-three 
gave a history of previous injury.''' 

My own experience has been limited, yet at least one-fourth 
of the cases coming under my observation have, presumably, re- 
sulted from trauma. 

The prevalent idea that wearing tight corsets, or the pressure 
made by carrying school-books against the breast, may induce 
lumps and indurations which tend to eventual malignancy, has not 
been substantiated by an}' authentic observations. 

In a small number of cases cancer of the breast has been pre- 
ceded by eczema or psoriasis of the nipple and areola, and 
Winiwarter found two cases of fat women with intertrigo, in whom 
carcinoma appeared in the sulcus where the skin of the breast 
passes into that of the thorax. 

Thus it is probable that a protracted irritation may give rise 
to carcinoma, the cause being rather in the continued irritation 
than in the characteristic form of skin disease. From these 
remarks the student may be convinced of the truthfulness of my 
first observation, namely, that but little is really known as to the 
etioloow of mammary cancer, it beino- left for the surgeon and 
gynecologist of the future to answer the perplexing question as to 
the etiology of this disease by a careful and systematic analysis of 
the history and pathological anatomy of those cases which are yet 
to arise. 

Symptoms and Diagnosis. — Carcinoma of the mamma is 
most frequently first made known by the accidental discovery of a 
small nodule or induration, usually situated near the base of the 
nipple, or in the upper axillary border. Less often the patient's 
attention is first called to it by the occurrence of lancinating pains, 



1) ArndTs System of Medicine, Vol. II, p. 528. 



512 A TEXT-BOOK OF GYNECOLOGY. 

while in some cases she first experiences a sensation of tension,, 
followed by the discharge of a serous, brownish, or bloody fluid 
from the nipple. Most often the nodule is first discovered, and 
continues to grow slowly for a year or more, before any pain or 
other symptoms are manifest. At this stage the diagnosis is of 
great importance, and is usually attended with considerable diffi- 
culty, often being impossible. It should be remembered that 
nodules or indurations found in the breast before puberty are almost 
invariably the result - of inflammation ; very rarely they are sar- 
comatous. If the patient is between twenty and thirty-five years 
of age, and the growth round, lobular and painless, growing 
slowly or not at all, it is probably a fibroma. If at the same age 
the growth is regular and uniform, either slow or rapid, it is prob- 
ably an adenoma, sarcoma or cysto-sarcoma. If the growth is 
very rapid and the tumor of soft consistence and not very painful, 
it is a medullary sarcoma. If both breasts enlarge to any consid- 
erable degree at about the time of puberty the growth is benign, 
being usually a progressive hypertrophy (Fig. 202). When, how- 
ever, the woman has passed the thirty-fifth year, when the indura- 
tion or nodule makes its appearance, and the latter cannot be iso- 
lated from the adjacent tissues, and continues to grow, and becomes 
harder, giving rise to more or less pain, it is doubtless carcinoma. 

The pain gradually becomes more constant and severe, and is 
described as burning or lancinating in its character, often causing 
the patient great and continual agony. In exceptional cases the 
pain is of a throbbing, gnawing or tingling character. If the axil- 
lary glands have become extensively involved, and adherent to the 
vessels and nerves, the patient will suffer intense neuralgic pains 
in the arm, which may become cedematous and, perhaps, finally 
end in enormous indurated elephantiasis of the entire member, as 
I have recently seen in a case of scirrhus of both breasts in a woman 
over sixty years of age. 

According to Gross (1), u among the earliest of these pheno- 
mena, particularly when the tumor is superficial, is a dimpling or 
pitting of the skin. This pitting is entirely independent of carci- 
nomatous adhesion between the skin and the growth, and arises 
from shortening of the fibrous bands or processes of the superficial 
mammary fascia which pass from the posterior surface of the skin 
into the interior of the breast, and which Sir Astley Cooper called 
the suspensory ligaments. This sign, together with the age of 
the patient and the consistence of the growth, enabled me to deter- 
mine the true nature of a tumor of the size of a small filbert, and 
of five months' duration, situated at the clavicular border of the 
gland, before its removal." 



1) Op. Cit., p. 146. 



CARCINOMA OF THE MAMMARY GLAND. 513 

As the tumor continues to grow it produces an interstitial 
cicatrization which causes a great and permanent retraction of the 
nipple by shortening the milk-ducts, which terminate at its extrem- 
ity. Gross says that " this process is the more apparent when 
the neoplasm develops in the immediate vicinity of the lacteal 
sinuses, or when the nipple itself is infiltrated and becomes the 
seat of cicatricial contraction. " It may be possible, however, that 
this retraction is sometimes only apparent, as the disease may have 
caused a swelling of the areola, so that the nipple, instead of being 
retracted, is simply surrounded by an elevation made by ' the 
swollen tissues. Retraction of the nipple occurs in a majority 
of cases of carcinoma of the breast and is of great diagnostic 
importance. 

Fixation of the tumor and axillary involvement occur at about 
the same time that retraction of the nipple takes place, as has 
been noted in a previous paragraph. 

As the disease progresses from this point, signs of constitu- 
tional involvement gradually become manifest, and the patient 
begins to lose strength; the digestive functions become impaired, 
nutrition is interfered with, the eyes become dull, the skin assumes 
a peculiar yellowish or "cachectic" appearance, the features be- 
come shrunken and emaciated, and the patient is continually rest- 
less, sleeping neither day nor night, even when the pain lessens, 
which seldom occurs except when it is mitigated by opiates. 

In the midst of these constitutional symptoms disintegration 
of the tumor sets in and follows a variable course, as has already 
been indicated in describing the clinical course of the disease. 

Pkognosis. — The prognosis of carcinoma of the breast has 
been previously considered in connection with the clinical course 
of the disease. It might be added that the prognosis is more un- 
favorable when the axillary glands enlarge, or when the tumor 
softens rapidly, or when the adjacent cutis shows small, hard, red- 
dish nodules, or, especially, if the disease extends rapidly from 
one breast to the other. 



CHAPTER LXIV. 



TREATMENT OF CARCINOMA OF THE MAMMARY GLAND. 

The treatment of mammary carcinoma, as of uterine carci- 
noma, may be either hygienic, constitutional, palliative or surgical. 
So far as the first three methods are concerned, the same remarks 
and rules apply as have already been given on page 289, and need 
not be repeated. I might say that in addition to the local appli- 
cations there mentioned, a lotion of Phytolacca, or a poultice of 
the fresh root, may be used to advantage in many cases. I consider 
Phytolacca the most valuable local agent in the treatment of nearly 
all forms of mammary tumors, and, when indicated by the symp- 
toms, its internal administration is not to be neglected. Plantago 
cerate is often useful, especially when a dry, eczematous condition 
exists about the nipple. Prof. Hall considers Rhatany cerate of 
most value in cases where ' ' the areola and base of the nipple crack 
easily and are inclined to bleed readily." Phosphorated oil is 
recommended as a local application by both Hall and Ludlam. I 
have also used it with apparent benefit. In its use, Hall advises 
that great caution \)e exercised. He says (1) that "if the applica- 
tion produces a diffuse redness or miliary rash, if there is coinci- 
dent disease of the os uteri, no application should be made to the 
breast that would have an effect to disperse the swelling there to 
the development of the uterine trouble, for the disease is better 
and more easily treated in the gland than in the uterus." 

Prof. Hall also recommends the following treatment accord- 
ing to indications:— 

" As the tumor gradually advances toward the stage of dis- 
integration, and the parts take on a pinkish or purplish hue, a 
compress of calendula and cosmoline will retard the ulcerative 
process and relieve the pain. 

' ' After the surface has become broken, there is an additional 
complication in the very offensive discharge of the hard cancer and 
in the hemorrhagic tendency of the soft cancer. In the former 
instances I have found great service from the following application: 

Pure gypsum 1 lb. ; 

Oil of tar 1 oz. 

Triturate well. 

"Toa small portion add sufficient olive oil, and mix until 
reduced to the consistency of cream. This may be spread upon a 

1) Arndt, Op. Cit., p. 542. 514 



TREATMENT OF MAMMARY CARCINOMA. 515 

piece of surgeon's-lint and applied to the ulcer. It absorbs and 
deodorizes the discharge, relieving the patient from the terrible 
stench. 

' ' If the discharge is profuse, the application should be changed 
frequently, as the plaster becomes very hard after it is saturated 
with the discharge. Dilute Listerine, a 10 per cent, solution of 
Piatt's chlorides, or a 10 per cent, solution of carbolic acid and 
glycerine may be used in the same manner. 

' k In soft cancer, when the hemorrhage is troublesome, styp- 
tic cotton, absorbent cotton saturated with a 10 per cent, solution 
of persulphate of iron, or cotton saturated with equal parts of 
Khatany and Pond's extract, will control the hemorrhage and give 
relief to the patient." 

Should there be considerable hypertrophy of the breasts they 
should be properly supported by means of straps and bandages. 

The breasts should be protected from cold and injury by being 
kept well covered with a layer of cotton wool, or some other pro- 
tective, and corsets or any article of dress producing compression 
should be dispensed with. The diet should be nutritious, but light 
and easily digested, and all symptoms of functional derangement 
should be promptly combated with the indicated remedy. 

The remedies mentioned on page 289 are equally useful in 
carcinoma of the mamma. I will give the chief indications for 
those only which are most often used. 

Arsenicum Album. — This is our most useful remedy in the 
treatment of all forms of carcinoma. The chief indication for its 
use is a burning pain in the growth. After ulceration has taken 
place there are dark-colored, offensive, ichorous discharges, severe 
burning and lancinating pains, rapid destruction of tissue, great 
restlessness and prostration; cachexia. 

Arsenicum Iodatum. — This remedy is said to be especially 
useful in epithelioma, and in cases originating from eczema. 

Carbo Animalis. — Scirrhus; cachexia well marked; tumor 
uneven, nodulated; skin loose, dirty, bluish-red spots; burning 
pain; pain drawing toward axilla. 

Conium. — The chief remedy in scirrhus; nodules and indura- 
tions in the gland, with burning or stitching pains; needle-like 
stitches; usually worse at night; breast abnormally tender. 

Cundurango. — According to Lilien thai (1) this remedy "is 
only efficacious in open cancer and cancerous ulcers, where it 
effectually moderates the severity of the pains. It does not act on 
scirrhus and indurated parts." 

Graphites. — Carcinoma originating from eczema, or develop- 
ing in nodules or cicatrices left after puerperal mastitis. 



1) Homeopathic Therapeutics, p. 



516 A TEXT-BOOK OF GYNECOLOGY. 

Hamamelis. — According to Hall this remedy is useful "in 
soft cancer, with hemorrhagic tendency and ecchymosed spots in 
different portions of the breast." 

Kreasotum. — Dwindling away of the mammas, with small, 
hard, painful lumps in them ; pungent, bloody, ichorous discharges ; 
rapid emaciation, weakness and prostration. 

Phosphorus. — Hard nodules, bluish color; sharp, lancinating 
pains; ulceration deep with indurated margins; fistulous openings, 
with burning, stinging pains, and watery, offensive discharges; 
bleeds easily; fungus nematodes. 

Phytolacca. — Especially useful in first stages; gland full of 
hard, painful nodosities; much swelling and inflammation; espe- 
cially during or soon after lactation. 

Removal by Caustics. — The method of removing carcinoma- 
tous growths from the mammary gland by means of caustics and 
escharotics, is, in the present advanced state of our knowledge, 
scarcely worthy of consideration. The time was when these agents 
were used extensively by the profession, but they are now, for the 
most part, relegated to the charlatan, who, taking advantage of 
the wide-spread prejudice existing against the use of the knife in 
cancerous affections, submits his patient to the protracted torture 
of this extremely painful, slow, and usually unsuccessful method 
of treatment. As Hall well says (1), "days, weeks and months 
are required to accomplish by caustics what, by the use of the 
knife, might be done in a few moments. " 

Hall, in the same article, very aptly exposes one of the spe- 
cious claims by which the so-called "cancer doctor" succeeds in 
imposing his method of "plaster" treatment upon the anxious 
but too credulous victim. He says:— tk The assurance of the 
advocate of the plaster that the operation is a painless one, a safe 
one, and a radical one, the ' roots ' of the cancer being removed, 
which it is impossible to do with the knife, is not entirely correct. 
The expression that the L roots ' are removed is, to say the least, 
unscientific. The small fibres which are attached to the growth 
when removed by the plaster, and called ' roots, ' are nothing more 
than portions of fibrous tissue. When the plaster is applied, the 
adipose and soft tissue are first destroyed, the dense or fibrous 
tissue remaining. When the mass is removed, these fibrous threads 
come away in strings and are called ' roots.'" 

He farther adds, "There can be no doubt that the removal 
of the breast by the knife, under the influence of an anaesthetic, is 
the quickest, safest, least painful, most radical, and in all respects 
the better mode of procedure." 

1) Arndt, Op. Cit., p. 545. 



TEE A TMENT OF MAMMA R Y C ARC IN OMA . 517 

With this opinion, all honest and intelligent physicians fully 
agree. 

Surgical Treatment. — At the present day there is very lit- 
tle question as to the advisability of an early removal of cancer- 
ous growths in the mamma?. While much benefit may be derived 
from constitutional treatment in retarding the progress of the dis- 
ease, and in relieving suffering, nevertheless, as has been previously 
shown by statistics, life is materially prolonged by an operation, 
and in very many instances where the operation has been performed 
before the deeper structures have become invaded and the lym- 
phatic glands involved, it has resulted in a radical cure. 

Hall (1) advises operation : — 

"First. Because it may cure, and because it does in the 
great majority of cases, according to the best collected statistics, 
prolong life from one to five years. 

" Second. The removal of the diseased tissue, even when the 
cancerous cachexia is present, is a great relief to the suffering 
patient. 

w w The weight, the pressure, and the local pain are removed. 
The foul, offensive, unhealthy ulcer disappears, and an open, 
healthy granulating surface takes its place. The condition of the 
patient is changed to one of tolerance, and even if her days are not 
prolonged, life will cease to be a burden.''' 

The methods of surgical treatment consist in (1) enucleation 
of the tumor, and (2) amputation of the breast, 

1. Enucleation. — Benign tumors, and small, cancerous 
nodules may be removed by enucleation, provided the adjacent 
structures and the lymphatics are not involved, though many sur- 
geons claim that even though the tumor be small, if we are certain 
of its cancerous nature the entire gland should be extirpated. 

In making this operation the incision should usually be made 
along the crescentric fold at the lower border of the gland, as in 
this manner the scar is effectually concealed. The gland is then 
turned up and the tumor enucleated with the handle of the scalpel 
or with the index finger. The edges of the wound are then brought 
into apposition and secured by sutures, union usually taking place 
by first intention. According to Gross, if ' ' the wound be a large 
one, a tent should be inserted into its most dependent portion, or 
at its lower angle, with the view to proper drainage, since, if pri- 
mary union throughout be attempted, experience shows that ery- 
sipelas, septicaemia, and pyaemia, are of not infrequent occurrence. " 
If the skin is ulcerated it is safer to remove the entire breast, but 
if enucleation is attempted the ulcerated tissue should be included 
between two curvilinear incisions radiating from the nipple back- 

1) Op. Cit.. p. 544. 



518 A TEXT-BOOK OF GYNECOLOGY. 

ward, the nipple being spared in every case in which it is possible 
to do so. 

2. Amputation of the Breast. — This operation is per- 
formed as follows : The anaesthetized patient is placed upon the 
table with the chest slightly elevated, the breast of the affected 
side near the edge, and the arm held off at a right-angle from the 
body, the light being so arranged that it will fall directly upon the 
part to be removed. The lines of incision are first outlined, being 
careful that they be made from one to two inches outside of the 
limit of induration. A large, stout scalpel is then passed through 
the skin and fat, to the aponeurosis of the great pectoral muscle, 
and carried around the breast so as to encircle it. The fascial 
covering of the thoracic muscles should be dissected up with the 
gland. If the infiltration has involved the deeper portions of the 
organ, the pectoral muscles within the line of incision should be 
dissected out, leaving nothing but the ribs and intercostal muscles. 
All bleeding vessels should be secured with artery-forceps, and 
ligated with catgut after the amputation is completed. 

The dissection should be made and the mass lifted from the 
sternum toward the axilla. In this way the larger vessels (the 
long thoracic artery and branches) are not divided until the incis- 
ion, which completely severs the tumor, is being made. 

The operator should now examine the wound and remove any 
suspicious tissue, or any outlying lobules of the gland, which are 
more often found in the axillary border of the incision. Gross 
then cauterizes the wound with Paquelin's cautery, but this is not 
the usual custom. Helmuth recommends thoroughly spraying the 
wound with a solution of carbolic acid. 

If any enlargement or induration of the axillary glands exist, 
these must now be extirpated. For this purpose the incision is 
carried from the existing wound up to the axillary space, after 
which the diseased glands are removed with the fingers, aided, if 
necessary, by closed scissors curved on the flat. If any vessels are 
torn they must be ligated at the proximal end at once, and if the 
axillary vein is torn it must receive a double ligature in order to 
prevent the admission of air and consequent septicaemia. Most 
often the long thoracic artery has to be tied, but if great care is 
exercised the operation can frequently be performed without the 
necessity of using any ligatures whatever in the axillary space. 
The axillary wound having been thoroughly cleansed, the surfaces 
at the upper portion are brought together with interrupted sutures, 
and free drainage provided by introducing and securing an oiled 
tent in the lower angle of the wound. In order to diminish the 
size of the large wound, resulting from the removal of the breast, 
the skin may be dissected for several inches from its deep connec- 



TREATMENT OF MAMMARY CARCINOMA. 519 

tions and several sutures inserted at a considerable distance from 
the edges, and then drawn nearer together. Gross recommends 
protecting the entire surface "by an oiled compress confined by 
adhesive strips and a broad roller, through the latter of which 
the arm is also fixed to the chest." 

Billroth thinks that * ' the danger of the operation is extraor- 
dinarily diminished by the antiseptic method," and recommends 
strongly that it should always be performed with strict antiseptic 
precautions. On the other hand, Gross never resorts to these pre- 
cautions. He says i ' the wound being an open one, there are no 
dangers to be feared from decomposing retained secretions or clots 
of blood, and the five patients that I subjected to the procedure 
all recovered under simple dressings. In the partial extirpations 
of the breast that I have practiced, I have also restricted myself 
to the compress of oiled lint, and I have never had reason to regret 
the practice. Whether the antiseptic treatment has diminished the 
mortality of the operations upon the mammary gland, it is impos- 
sible to say from any very extended experience, although the 
observations of Oldekop on this point are not in its favor." 

According to Gross the dressings should not be removed, ex- 
cept the weather be very warm, under three days, when a slippery- 
elm poultice may be "'substituted for the oiled lint, and the tent 
be removed from the axilla, the wound being kept open subse- 
quently Irr the daily insertion and expansion of the blades of the 
dressing-forceps. The sutures should be permitted to remain as 
long as they are doing good. With the view of promoting the 
granulating process, when cicatrization is well established, the 
surface may be touched daily with a weak solution of nitrate-of- 
silver; or healing may be expedited, when the wound is very large, 
by epidermic grafting." 

Amputation of the breast, especially if the axillary glands 
are also to be removed, is a more formidable operation than the 
neophyte might suppose, and, on account of the great danger of 
wounding important vessels and bringing about fatal hemorrhage, 
it should not be attempted by one who has had no experience, or, 
at least, who has never witnessed the operation. 



APPENDIX. 



Dry Heat in the Treatment of Uterine Diseases. 

I have received from Prof. Phil. Porter, M.D., just in time 
for its insertion in the Appendix, a description of the instrument 
which he has devised for the treatment of diseases of the uterus 
by the application of dry heat to the endometrium. 

Prof. Porter says: 

c ' The benefit to be derived from the use of heat, either dry 




Fig. 212. — Porter's dry heater for uterus and bladder.. 

or moist, in the treatment of diseases of the uterus, has long 
been known. Owing to the great sensitiveness of the uterus, and 
its peculiar formation, the practice of injecting hot water into its 
cavity has been almost entirely abandoned. In order to obtain 
the advantages of the use of heat, and yet avoid the deleterious 




Fig. 213. — Porter's dry heater for vagina and rectum. 



agent 



was 



effects of former methods of treatment in which this 
employed, it occurred to me that the object might be best attained 
by means of dry heat. Accordingly, I devised the instrument 
which is illustrated in Fig. 212. In my hands it has proved to 
be perfectly adapted to the purpose desired. It was suggested to 
my mind by having seen an instrument which was used by Drs. 
Hamilton and Palmer, of Minneapolis, for the treatment of rectal 

520 



APPENDIX. 521 

ulcers in phthisical subjects. I recalled, also, some remarks on 
the subject of the treatment of disease by dry heat, made by Dr. 
Albert Claypool, of Toledo, at the meeting of the American Insti- 
tute of Homeopathy, in 1887. Acting upon the suggestions thus 
received, I had this instrument made. It is so constructed as to 
be used either for the uterus or for the female bladder. It con- 
sists of a metal tube nine inches long, insulated throughout its 
entire length, except about three inches from the tip. This insula- 
tion renders it possible to use the instrument without passing it 
through a speculum, and. while the degree of heat attained within 
the uterus may be from 125° to 145° F., the vagina is exposed to 
no corresponding rise of temperature. A similar protection is 
afforded the urethra when the instrument is introduced into the 
female bladder. Two sizes of these instruments are made, the 
smaller to be used in a uterus in which dilatation is impracticable, 
but for ordinary purposes the larger one is to be preferred. 

" This instrument I can confidently recommend in the treat- 
ment of that class of uterine and vesical disorders in which the 
pathological changes are dependent upon some nutritive disturbance. 
Subinvolution, areolar hyperplasia, chronic metritis, endometritis, 
cervicitis, are all quickly relieved, by having the vascular supply 
to the organ much improved. 

"The method of applying the dry heat treatment to the 
uterine cavity is as follows: The patient is placed in the latero- 
abdominal position, with the hips brought well down to the edge 
of the chair or table. Until somewhat familiar with the use of 
the instrument, the retractor should be employed to expose the 
cervix. It is assumed that the patient has previously been exam- 
ined, and the size of the tube to be selected for use has been 
determined by the introduction of a whale-bone or silver-wire 
probe. The point of the heater should then be passed to the 
fundus uteri. If there is no obstruction at the internal os, a steady 
pressure upon the instrument will usually be sufficient, but if it 
produces pain, the tip of the heater should be allowed to remain, 
and the hot water turned on; this will in a short time cause suffi- 
cient relaxation to permit the tube to pass into the cavity of the 
uterus. If the speculum has been employed, it may now be with- 
drawn, for the sake of the patient's comfort. The heater once in 
place, it is retained there, and the temperature is gradually raised 
to about 145 ° F. The uterus is not so richly supplied with nerves 
of sensation as are the bladder, vagina and rectum, so that the 
endometrium may be burnt without eliciting any cry of pain from 
the patient. However, it is well to have a thermometer attached 
to the tank containing the hot water, so that the degree of heat 
may be intelligently regulated. 



522 APPENDIX. 

4 c At first, especially in cases of metritis, the patient will com- 
plain of a bearing-down sensation, but this soon passes off, and 
nothing but a warm, comfortable feeling is experienced. The 
treatment should be continued from twenty minutes to half-an-hour, 
according to the endurance and comfort of the patient. In cases 
marked by hemorrhage, it is well to prolong the application as 
long as an hour. The larger sized tube should be selected when- 
ever it is practicable. 

u When employing the heater for the urethra or bladder, the 
greatest care should be exercised at first, the parts being particu- 
larly sensitive. It is my plan to deposit a few drops of a 10 per 
cent, solution of cocaine with an ordinary glass dropping-tube, 
made by heating and slightly curving a piece of glass tubing, about 
six inches long, and having a rubber nipple at the end. This glass 
tube is an excellent instrument for the purpose of depositing a few 
drops of any desired liquid within the uterus. 

tk A few minutes after the cocaine has been deposited within 
the urethra or bladder, the heater can be introduced without dis- 
comfort. A few treatments will usually relieve the bladder of the 
tenesmus, and the tube can be placed in position without the use 
of cocaine. The bladder should be first emptied with a soft-rubber 
catheter having as small eyelet holes or apertures as can be 
obtained.* 

" Applications to the urethra will vary with the nature and 
locality of the disease, the metal portion of the tube being placed 
directly against the affected part. The vagino-rectal tube is, as 
its name implies, employed both for the vagina and the rectum. 
For ordinary vaginal irritations, like vaginitis, the tube is to be 
introduced, brought to the desired temperature, and allowed to 
remain in position for the usual length of time. It will be found, 
with but few exceptions, that in vaginal troubles there will also be 
rectal complications, the vaginitis being of a secondary nature. 
The only instructions to be given relative to the introduction of 
the vaginal tube is that the end of the tube should be passed well 
up to, and under, or behind, the cervix uteri. If the patient be 
placed in the latero-abdominal position, there will be but little 
trouble in introducing the tube, especially if the fore-finger is intro- 
duced within the vagina, and the latter retracted so as to admit air. 

u The rectal heater, as an adjunct to the treatment of the 
pelvic disorders of women will prove to be of great value. I am 
satisfied of the great relative frequency of this class of complaints 



* The presence of a large eyelet hole in a female catheter is often the cause of much injury 
to the interior of the bladder. The ordinary sized eyelet in a catheter causes the instrument 
to yield at this point, and when grasped by the bladder or urethra the mucous membrane 
becomes engaged, by being forced down into the sulcus thus formed, and when the instrument 
is withdrawn the delicate tissue may be abraded or lacerated. 



APPENDIX. 523 

in connection with uterine disorders, and the successful practitioner 
will prove to be the one who studies the pathology and condition 
of rectal maladies in their relation to that of uterine disease. The 
recto-vaginal tube is six inches long by one inch in diameter, 
insulated by one and one-half inches at the base, so as to protect 
the tissue at the junction of the skin and mucous membrane, which 
is a very sensitive point. In conjunction with local applications, 
it can be utilized for the treatment of any rectal disorder, but I 
employ it only for its effect upon the vascular supply to the part, 
to correct the nutrition of the rectum and the adjacent connective 
tissue. The continued action of the heat soon creates a change in 
the state of the tissues, and relieves the over-distended vessels." 



Serrated Scissors and Compound Tenaculum for Amputation of the 

Cervix Uteri, and for the Removal of Pedunculated 

and Sessile Tumors from the Cervix. 

My attention has but recently been called to the above-named 
instruments (Figs. 214, 215), devised by Dr. W. H. Wathen, of 
Louisville, Ky., through an article appearing in the New York 
Medical Journal, September 1, 1888. I am so favorably impressed 
with their probable utility in the operations named, that I have 
concluded to quote Dr. Wathen's remarks concerning their use. 
He says that he devised the instruments in 1877, and has "used 
them since in amputations of the cervix uteri and for the removal 
of tumors from the cervix.. It will be observed that the scissors 
is made after the fashion of an ordinary scissors, bent at right- 
angles on the flat, with the blades slightly curved on the edge and 
finely and sharply serrated. It cuts by a rotary motion; and an 
indurated cervix, or a hard fibroid tumor with a base two inches 
in diameter, may be removed by it in a few minutes, with no more 
hemorrhage than usually follows the use of the ecraseur. It affords 
the best and the safest means to perform these operations, and in 
amputations of the cervix, the mucous membrane of the intra- 
cervical and the extra-cervical tissues may be brought together 
and will leave no open wound to absorb septic matter, or to heal 
by granulations, and probably cause cicatricial contraction of the 
canal, such as often follows amputations by the ecraseur or the 
galvano-cautery. This scissors has recently been much improved, 
and has been made more powerful and more aseptic. But it is 
necessary to have a strong double tenaculum forceps, so that the 



524 



APPENDIX. 



cervix or tumor may be held steady while being removed by the 
rotary or sawing motion of the scissors. I have improved the 
ordinary tenaculum by combining it with another, to be introduced 
into the os in amputations of the cervix and fastened into the tissue 
of the cervical canal. By this means we may remove a cone- 
shaped piece by pulling down the intra-cervical tissue before intro- 
ducing the outer teeth of the tenaculum into the vaginal mucous 
membrane of the cervix; and by pulling gently on the tenaculum 





Fig. 214. — Watheii'S; serrated 
scissors. 



Fig. 215. — Wathen's compound 
tenaculum. 



during the process of amputation, the excavation into the uterus 
will thereby be increased. There is no necessity of dividing the 
mucous membrane high up, and therefore the danger of cutting 
into the peritoneum is relatively less. With this scissors and te- 
naculum the excision may be performed without risk of wounding 
any part of the vagina. ^The tenaculum can be immediately sepa- 
rated into its four parts, so as to be perfectly cleansed and made 
aseptic. " 



APPENDIX. 525 

A New Abdominal Electrode. 

Dr. Ely Van de Warker has devised a new abdominal electrode, 
which he considers superior to the clay electrode of Apostoli, de- 
scribed in Chapter XXI, and which is certainly preferable from 
the standpoint of neatness and convenience. Dr. Van de Warker 
describes his electrode as follows: — U A circular disk of zinc, to 
which is connected the binding-post, has attached to its periphery, 
by solder, half a dozen fine copper wires eight inches long, or of 
sufficient length to reach across the electrode, which are loosely 
tucked, as the needlewomen call it, to a piece of thick, firm 
chamois-skin, cut the shape and size of the intended electrode. 
Upon this is laid another piece of chamois-skin of the same size, 
and the two are quilted together in rows parallel to each other, and 
about two-thirds of an inch apart. The spaces thus made are 
filled with fine shot. A thin vulcanized plate, the same size as the 
zinc disk, is interposed between the chamois-skin and the zinc, on 
the contact side of the electrode, so that the current will be 
diffused through the latter, and not directly from the zinc. The 
copper wires should be tacked to the upper and not the contact 
side of the electrode. The electrode is prepared by being dipped 
in water until it is saturated, and thus the chamois-skin becomes as 
perfect a conductor as water can make it." 



INDEX OF AUTHOES. 



Alexander, 233 
Apostoli, 173, 186, 265, 379 
Aran, 314 
Arnold, 137 

B 

Baer, 368, 371 
Baldwin, 343 
Bandl, 451, 454, 458, 462, 463, 464, 

466, 468 
Barnes, 12, 14, 16, 18, 305, 312, 

421, 429, 444, 453 
Beard and Rockwell, 265 
Bechtinger, 469 
Bennett, 326 
Biegel, 8, 447 
Billroth, 470, 473, 474, 481, 484, 

488, 489, 492, 495, 496, 498, 

504, 506, 507, 509, 519 
Blackwood, 463 
Bozeman, 126 
Boinet, 346 
Bruce, 438 
Byford, 9, 60, 258 

c 

Campbell, 306 
Churchill, 7, 291 
Comstock, 126, 158 
Courty, 141, 240 
Cruveilheir, 140 

D 
DeGraf, 328 
De Sinety, 167, 168 
Dolbeau, 390 
Doutrelepont, 71, 504 
Drysdale, 326 
Dudley, 233 
Dudgeon, 342 
Duncan, 311 
Dunham, 342 % 

Eaton, 346 

Edwards, 9 

Emmett, 95, 111, 113, 117, 125, 
153, 154, 157, 159, 206, 237, 
240, 242, 243, 261, 292, 299, 
302, 325, 344, 350, 351, 352, 
363, 370, 372, 377, 389, 391, 
446 

F 

Fellows, 435 

Frankenhseuser, 22 

Fritsch, 44, 75, 96, 211, 214, 227, 
256, 420, 433, 435, 439 



465, 

388, 



487, 
500, 



141, 
238, 
301, 
355, 
433, 



239, 



G 

Gallux>e, 342 

Oatchell, 299 

Girault, 448 

Goodell, 156, 224, 295, 296, 315, 318, 

329, 343, 352, 360 
Grandin, 45, 51 
Grohe, 21 
Gross, 484, 485, 486, 488, 493, 496, 500, 

503, 504, 506, 508, 509, 512, 517, 

518, 519 
Guernsey, 314, 342, 434 

H 

Hamilton, 

Hahnemann, 29 

Hale, E. M. 171, 445, 448 

Hale, P. H. 341 

Hall, 504, 511, 514, 516, 517 

Harris, 477 

Hart and Barbour, 6, 19, 36, 51, 86, 
115, 123, 145, 146, 149, 150, 162, 
170, 172, 198, 222, 227, 230, 252, 
278, 281, 351, 359, 362, 366, 379, 
386 

Hecker, 453 

Hegar, 118, 147, 263 

Helmuth, 83, 341, 489, 501, 518 

Henle, 6 

Hildebrandt, 72 

Holcombe, 432 

Hughes, B. 342 

Hughes, 326 

Huguier, 147 

Jackson, M. B. 342 
Jackson, 292 
Jenks, 114 

K 

Kaltenbach, 263 
Keith, 359 

Kimball and Cutter, 
Kiwisch, 459, 464 
Klebs, 277, 504 
Klob, 178, 453, 473 
Klotz, 493 
Koch, 71 



265 



Leavitt, 471 
Legendra, 201 
Lilienthal, 404, 
Link, 354 _ 
Lowenstein, 7 



515 



521') 



INDEX OF AUTHORS. 



527 



Ludlam, 76, 109, 165, 204, 257, 290, 
309, 315, 319, 338, 341, 349, 354, 360, 
361, 379, 380, 381, 403, 413, 432 

M 

McDowell, 348 
Mitchell, 182, 315, 483 
Muller, 497 

N 

Niemever, 430 
Noeggerath, 240, 365, 446 
Nott, 221 

o 
Obetz, 354 
Oldham, 411 
Olshansen, 167, 168 

P 

Palmer, 178 
Palmer, L. R. 
Parvin, 456, 465 
Payne, 341 
Pean, 357 
Peaslee, 328, 350 
Perry, 456 
Piersons, 341 
Pinolini, 247 
Playfair, 182 
Porter, 44, 520 
Pratt, 57, 224 

R 
Ranney, 20 

Rindfleisch, 319, 325, 328, 504 
Robert, 470 
Rokitansky, 323, 328 
Roser, 475 
Rnge and Viet, 161, 167, 283 



Sappey, 2, 10, 11, 475 

Savage, 4, 9 

Scanzoni, 108, 318, 411 

Schroecler, 44, 98, 123, 147, 148, 174 

237, 244, 277, 280, 283, 311, 323, 

364, 386, 454, 467 
Schultze, 15, 190 
Sequin, 88 



Seyfort, 289 

Simmonds, 504, 507 

Simon, 37, 133, 135 

Simpson, 86, 145, 153, 287, 414 

Sims, 100, 101, 117, 145, 152, 224, 292 

Small, 341 

Smith, Julia H. 308, 476, 482 

Smith, Tyler, 420 

Spiegelberg, 3, 286 

Stevenson, 187, 272 

Stilling, 496 

Storer, 7 

Sumner, 342 



Tait, 241, 302, 384, 385 

Thomas, 27, 28, 85, 87, 119, 152, 161, 
163, 164, 172, 177, 178, 198, 203, 
223, 229, 235, 236, 238, 248, 262, 274, 
279, 287, 288, 291, 316, 317, 328, 330, 
331, 339, 347, 364, 365, 387, 394, 401, 
445, 447, 454, 458, 459, 462, 463, 464, 
465, 467 

Thorburn, 232, 233, 248, 298, 368, 376, 
448 

V 

Valkman, 509 

Van de Warker, 13, 525 

Velpeau, 481, 493, 494 

Virchow, 245, 247, 248, 277, 430, 497 

W 

Waldeyer, 19, 280, 323, 326 

Wathen, 523 

Wells, 361 

Wesselhoeft, 341 

Williams, 410 

Winckel, 64, 65, 66, 67, 70, 82, 84, 90, 
92, 97, 103, 168, 182, 214, 248, 256, 
258, 278, 284, 286, 294, 295, 298, 
300, 324, 335, 370, 386, 411, 470, 
482, 497 

Winiwarter, 509, 511 

Winterbum, 205, 402, 403, 404, 411 

Wormald, 493 

z 

Ziegler, 280 



INDEX. 



Abdominal examination, 34 

gestation, 452 

ovariotomy, 349 
Abortion as a cause of disease, 27 
Abscess, pelvic, 382 

of the mammary glands, 473 
Absence of the ovaries, 304 

of the mammary glands, 469 

of the uterus, 138 

of the A 7 agina, 90 

of the vulva, 64 
Adenoma of the mammary glands, 488 
Allen's surgical pump, 53 
Alexander's operation, 233 
Amazia, 469 
Amenorrhea, 394 
Amputation of the cervix, 144, 212 

of the coccyx, 89 

of the mammary gland, 518 

of the uterus, 243 
Anatomy of the genital organs, 1 
Anteflexion of the uterus, 220 
Anteversion of the uterus, 210 
Apostoli's treatment of inflammation 

by electricity, 186 
Apostoli's treatment of fibroid tum- 
ors by electricity, 265 
Areolar hyperplasia, 177 
Artificial impregnation, 448 
Ascent of the uterus, 198 
Aspirator, the, 61 
Atresia of the cervix, 148 

of the hymen, 92 

of the vagina, 92 

of the vulva, 64 
Atrophy of the ovaries, 304 

of the uterus, 142 

of the uterus, congenital, 140 
Aveling's polypotome, 259 



Barrenness, 444 

Battey's speculum, 44 

Benign tumors of the mammary 

glands, 485 
Bi-manual examination, 35 
Bi-valve specula, 40 
Bladder, anatomy of, 7 
Blennorrhea, 97, 419 
Bozeman's apparatus for fistula, 126 

fork, 130 

speculum, 43 



Breast, diseases of, (see mammary 

glands) 469 
Broad ligaments, anatomy of, 10 

cysts of, 294 
Byford's curette, 60 

retroversion pessary, 219 



Carcinoma of the mammary glands, 
503 

of the ovaries, 316 

of the uterus, 280 

of the vulva, 72 
Caruncle of the urethra, 86 
Case book, 29 

Cataclysmic hematocele, 388 
Catarrhal vulvitis, 81 
Catarrh of the cervix, 161 
Causes of gynecological disease, 25 
Cellulitis, pelvic, 370 
Cervical catarrh, chronic, 161 

dilators, 50 

endometritis, chronic, 161 
Cervix, amputation of, 144, 292 

atresia of, 148 

catarrh of, 161 

cystic degeneration of, 162 

dilatation of, 151 

granular degeneration of, 162 

hypertrophy of, 143 

incision of, 151 

laceration of, 153 

stenosis of, 149 
Chair, gynecological, 31 
Chlorosis, 428 

Chapman's stem pessary, 224 
Chassaignac's ecraseur, 31 
Chondroma of the mammary glands, 

487 
Clitoris, anatomy of, 3 
Cloaca of the vagina, 91 
Closure of the vagina, operation for, 

132 
Coccyodynia, 88 
Coccyx, amputation of, 89 
Cockscomb granulations of cervix, 

162 
Colpitis, 97 

Comstock's gynapod, 126 
Congenital atrophy of the uterus, 

140 
Congestive dysmenorrhea, 407 
Corporeal endometritis, chronic, 167 
Curette, the, 59 



528 



INDEX. 



529 



disco's speculum, 40 

Cutter's pessary, 232 

Cystocele, 104 

Cystic degeneration of the cervix, 162 

Cysts, dermoid, 319 
tubo-ovarian, 301 
of the broad ligament, 295 
of the mammary glands, 492 
of the ovaries, 318, 322 
of the parovarium, 295 
of the vulva, 68 

I) 

Dawson's ovarian clamp, 358 

speculum, 45 
Descent of the uterus, 198 
Dermoid cysts of the ovary, 319 
Diagnosis of gynecological diseases, 

29 
Diffuse h} T pertrophy of the mam- 
mary glands, 489 
Dilatation of the cervix in anteflex- 
ion, 223 

in stenosis, 151 
Dilators, cervical, 50 
Displacements of the ovaries, 305 

of the uterus, 197 
Drainage in ovarian cysts, 345 
Dry heat in uterine diseases, 520 
Dysmenorrhea, 406 



Ecraseur, the, 259 
Ectopic gestation, 450 
Electricity in uterine and peri-uter- 
ine inflammation, 186 

in fibroid tumors, 265 
Elephantiasis, 69 
Elevator, Guernsey's uterine, 216 
Ellinger's dilator, 58 
Elliott's uterine repositor, 216 
Elythritis, 97 
Elytrorrhaphy, 117 
Elytrotomy in extra-uterine gesta- 
tion, 463, 466 
Emmett's bistouries, 128 

double tenaculum, 157 

dilator, 53 

enucleator, 261, 

method of elytrorrhaphy, 117 

method of periorrhaphy, 111 

ovarian trocar, 356 

perineal retractor, 45 

pessary, 207 

scissors, 128 

twisting forceps, 131 
Encephaloma of the mammary 

glands, 504 
Endocervicitis, 161 
Endometritis, cervical, chronic, 161 

corporeal, chronic, 162 

therapeutics of, 423 

treatment by electricity, 186 



Enterocele, 105 
Entero-vaginal hernia, 105 
Enucleation of the mammary gland, 

517 
Episiorrhaphy, 121 
Epispadias, 65 
Epithelioma of the mammary gland, 

504 
Eruptive diseases of the vulva, 74 
Etiology of gynecological diseases, 25 
Examination and diagnosis, general, 

29 
Extirpation of the uterus, 292 
Extra-uterine gestation, 450 
treatment of, 461 



Fallopian tubes, anatomy of, 16 

diseases of, 297 

inflammation of, 297 

malformations of, 297 

morbid growths in, 302 

stricture of, 297 
Fergusson's speculum, 39 
Fibroid tumors of the uterus, 244 
Fibroma of the mammary gland, 485 

of the ovaries, 317 

of the uterus, 244 

of the vulva, 69 
Fibro-myoma of the uterus, 244 
Fistula, recto-vaginal, 134 

vesico-vaginal, 123 

vesico-vaginal, operation for, 125 

vaginal, 122 
Fitch's uterine sound, 49 
Fluor albus, 419 
Fcetation, extra-uterine, 450 
Follicular vulvitis, 83 
Fossa navicularis, 5 
Fowler's pessary, 207 

G 

Gangrenous vulvitis, 84 
Gastrotomy in fibroids, 262 
Gehrung's anteversion pessary, 212 
General etiology of gynecological 

diseases, 25 
Gestation, abdominal, 452 

extra-uterine, 450 

interstitial, 451 

in rudimentary horn, 454 

ovarian, 453 

tubal, 451 

tubo-abdominal, 452 

tubo-ovarian, 451 

tubo-uterine, 451 
Gonorrheal vulvitis, 82 
Goodell's dilator, 58 

perineum needle, 108 
Graafian follicles, 19 
Grandin's speculum, 45 
Granular degeneration of cervix, 162 



530 



INDEX. 



Graves' speculum, 40 
Guernsey's uterine elevator, 216 

H 

Hsematometra, 148 
Hemorrhage of the ovaries, 305 
Hahnemann's rules for examination, 

29 
Hale's speculum, 40 
Hank's dilators, 54 
Hart and Barbour's method of am- 
putating cervix, 145 
Hegar's method of amputating cer- 
vix, 145 

of elytrorrhaphy, 118 
Hematocele, pelvic, 386 
Hematoma of the vulva, 73 
Hemato-salpinx, 301 
Hermaphrodism, 66 
Hernia, entero-vaginal, 105 

of the vulva, 67 

of the ovaries, 307 

recto-vaginal, 105 

vesico-vaginal, 104 

vaginal, treatment of, 107 
Hewitt's cradle pessary, 212 
Hitchcock's anteversion pessary, 

213 
Hodge's pessary, 207 
Hoffman's retroversion pessary, 218 
Hunter's speculum, 45 
Hydrocele, 294 
Hydrometra, 148 
Hydro-salpinx, 300 
Hydrops follicularis, 323 
Hymen, anatomy of, 5 
Hyperesthesia of the vulva, 85 
Hypertrophy of the mammary 

glands, 489 
Hypospadias, 65 
Hysteria, 433 
Hysterotome, 151 



Imperfect development of ovaries, 

314 
Impregnation, artificial, 448 
Incision of cervix in stenosis, 151 
Infarctus, chronic, 177 
Infecundity, 444 

Inflammation of the Fallopian tubes, 
297 

of the mammary glands, 473 

of the ovaries, 311 

of the uterus, 174 

of the uterus, chronic, 177 

of the vagina, 97 

of the vulva, 81 
Instrumental examination, 39 
Interstitial gestation, 451 
Inversion of the uterus, 236 
Iodine, injection of in ovarian cysts, 
348 



J 

Jackson's cervical ueedle, 158 

retractor, 45 

speculum, 40 

stem pessary, 224 
Jenk's perineum scissors, 110 

plan of denudation, 114 

spiral sound, 50 
Jennison's douche, 171 

K 

Kolpokleisis, 33 

Simon's operation for, 36 



Labial hernia, 67 

Labia majora, anatomy of, 1 

minora, anatomy of, 2 
Laceration of the cervix, 153 

of the perineum, 108 
Laminaria tents, 50 
Lateroflexion of the uterus, 234 
Lateroversion of the uterus, 219 
Laparotomy for fibroid tumors of 
the uterus, 262 

for extra-uterine gestation, 463, 464 
Leucorrhea, 419 
Lipoma of the mammary gland, 486 

of the vulva, 69 
Ligaments, uterine, diseases of, 294 
Lupus of the vulva, 71 

M 

Malformations of Fallopian tubes, 297 

of vagina, 90 

of vulva, 64 
Malignant tumors of the mammae, 495 
Mammary glands, absence of, con- 
genital, 469 

abscess of, 473 

adenoma of, 488 

benign tumors of, 485 

carcinoma of, 503 

chondroma of, 487 

cysts of, 492 

diffuse hypertrophy of, 489 

diseases of, 469 

epithelioma of, 504 

encephaloma of, 504 

fibroma of, 485 

inflammation, 473 

lipoma of, 486 

malignant tumors of, 495 

medullary carcinoma of, 504 

neuralgia of, 481 

osteoma of, 487 

sarcoma of, 495 

scirrhus of, 503 

supernumerary, 469 

tumors of, 484 
Mann's speculum, 45 
Manual examination, 33 
Mammitis, 473 



INDEX. 



581 



Mastitis, 473 

Mastodyuia, 481 

Medullary carcinoma of the mamma, 

504 
Meig's ring pessary, 207 
Membranous dysmenorrhea, 410 
Metritis, acute, 174 

chronic, 177 

chronic, treatment of by electrici- 
ty, 186 

diffuse interstitial, 177 
Metrorrhagia, 399 
Metrotome, 151 
Miller's speculum, 40 
Mitchell's, S. Weir, rest treatment, 

182, 440, 482 
Molesworth's dilator, 53 

acme, 58 
Mons veneris, anatomy of, 1 
Morbid growths of Fallopian tubes, 

302 
Mucous polypi of the uterus, 273 
Myoma, 244 

Needle-holder, Russian, 158 

Nelaton's forceps, 356 

Nelson's speculum, 40 

Nerves supplying genital organs, 23 

Neuralgia of the coccyx, 88 

of the ovaries, 308 

of the mammary glands, 481 
Neuralgic dysmenorrhea, 408 
Nipple, retracted, 470 

sore, 470 
Nott's speculum, 40 
Nymph ae, anatomy of, 2 

o 
Obstructive dysmenorrhea, 413 
(Edema of the vulva, 74 
Oophoralgia, 308 
Oophoritis, 311 

Osteoma of the mammary gland, 487 
Ovaralgia, 308 
Ovarian cysts, 318, 322 

dermoid cysts, 319 

gestation, 453 

irritation, 308 

ligaments, anatomy of, 16 

neuralgia, 308 

tumors, 316 
Ovaries, abseuce of, 304 

anatomy of, 16 

atrophy of, 304 

diseases of, 304 

displacements of, 305 

hemorrhage of, 305 

hernia of, 307 

imperfect development of, 304 

inflammation of, 311 

neuralgia of, 308 

tumors of, 316 
Ovaritis, acute, 311 

chronic, 313 



Ovariotomy, 348 
Oviducts, anatomy of, 16 
Ovulation, process of, 19 



Palmer's dilator, 58 
Paquelin's thermo-cautery, 359 
Paracolpitis, 370 
Parametritis, 370 
Parovarian cysts, 298 
Parovarium, anatomy of, 21 
Peaslee's aspirator, 61 

perineum needle, 108 

uterotome, 152 
Pelvic abscess, 382 

cellulitis, 370 

hematocele, 386 

peritonitis, 364 

phlegmon, 370 
Perimetritis, 364 
Perineorrhaphy, 107 
Perineum, lacerated, 108 

needles, 108 
Peri-oophoritis, 311 
Peritonitis, pelvic, 364 
Peri-uterine cellulitis, 370 

inflammations, treatment by elec- 
tricity, 186 
Pessaries, varieties of, 207, 212, 213, 
218, 219, 232, 233, 234 

block tin, 232 

intra-uterine stem, 224 

their use in displacements, 204 
Physical examination, 31 
Physometra, 148 
Polymazia, 469 
Polypi of the uterus, 273 
Polypotome, Aveling's, 259 
Polypus forceps, 275 
Porter's speculum, 44 

dry heater for the uterus and blad- 
der, 520 
vagina and rectum, 520 
Pratt's method of dilating with steel 

sounds, 57 
Pregnancy, extra-uterine, 450 
Prolapsus of the urethra, 87 

of the uterus, 198 

of the vagina, 103 
Pruritus vulvae, 75 
Pudendal hernia, 67 
Pump, Allen's surgical, 53 
Pyometra, 148 
Pyo-salpinx, 298 

R 

Rational history of disease, 29 
Recauner's curette, 59 
Rectal examination, 36 
Rectocele, 105 
Recto-vaginal hernia, 105 
fistula, 134 



532 



INDEX 



Repositor, uterine, Elliott's, 216 

Sim's, 216 

White's, 240 
Retracted nipple, 470 
Retractor, perineal, 42 
Retroflexion of the uterus, 226 
Retroversion of the uterus, 213 
Retro-uterine hematocele, 386 
Round ligaments, anatomy of, 10 

tumors of, 294 
Rudimentary uterus, 138 

vagina, 90 



Salpingitis, 297 

Sarcoma of the mammary gland, 495 

of the uterus, 277 

of the vulva, 72 
Scirrhus of the mammary glands, 503 

of the uterus, 280 
Simon's curette, 59 

flat steel hooks, 44 

operation for kolpokleisis, 136 

rectal examination, method of, 38 

retractor or plate, 44 

speculum, 43 
Sims' curette, 59 

depressor, 43 

dilator, 58 
vaginal, 96 

method of amputating cervix, 145 

operation for vaginismus, 101 
for elytrorrhaphy, 117 

rotary knife, 129 

sigmoid catheter, 131 

speculum, 42 

uterine repositor, 216 
sound, 49 

wire adjuster, 132 
Simpson's curette, 60 

method of amputating cervix, 145 

uterine sound, 47 
Skeene's perineum needle, 108 
Slippery elm tents, 51 
Smith's, Albert, pessary, 207 
Sore nipples, 470 
Sound, uterine, 47 

in diagnosis, 48 

method of introduction, 48 

in replacement of uterus, 230 
Sounds, graduated steel, 56 
Spansemia, 428 
Specula, varieties and advantages of, 

39 
Sponge tents, 50 
Spoon saw, Thomas', 262 
Stenosis of the cervix, 149 
Sterility, 444 

Stricture of Fallopian tubes, 297 
Subinvolution of the uterus, 177 
Superinvolution of the uterus, 142 
Supernumerary mammary glands, 
469 



Tait's dilators, 54 

operation, 302 
Tapping in ovarian cysts, 343 
Tent applicators, 52 
Tents, varieties of, 50 
Thomas' cervical plug, 152 

curette, 59 

method of elytrorrhaphy, 119 

ovarian clamp, 358 

pessary, 207 
anteversion, 213 
latero-flexion, 234 
retroversion, 218 
ring, 208 

spoon saw, 358 

uterine sound, 49 
Truax's dilator, 58 
Tubal gestation, 451 
Tubo-abdominal gestation, 452 
Tubo-ovarian cysts, 301 
Tubo-ovarian gestation, 451 
Tubo-uterine gestation, 451 
Tumors of the mammary glands, 484 

of the ovaries, 316 

of the round ligaments, 294 

fibroid, of the uterus, 244 
Tunica albuginea, 18 
Tupelo tents, 50 

u 

Urethra, anatomy of, 7 

prolapsus of, 87 
Urethral caruncle, 86 
Uterine cervix, amputation of, 144, 
292 

atresia of, 148 

catarrh of, 161 

cystic degeneration of, 162 

dilatation of, 151 

granular degeneration of, 162 

hypertrophy of, 143 

incision of, 151 

laceration of, 153 

stenosis of, 149 
Uterine changes in extra-uterine ges- 
tation, 455 

elevator, Guernsey's, 216 

ligaments, diseases of, 294 

repositors, 216 
White's, 240 
Uterotome, 151 
Utero-sacral ligaments, anatomy of, 

10 
Utero-vesical ligaments, anatomy of, 

10 
Uterus, absence of, 138 

amputation of, in inversion, 243 

anatomy of, 9 

anteflexion of, 220 

anteversion of, 210 

ascent of, 198 

atrophy of, 142 



INDEX. 



533 



bicornis, 139 

carcinoma of, 280 

congenital atrophy of, 140 

congestive hypertrophy of, 174 

descent or prolapsus of, 198 

diseases of, 137 

displacements of, 197 

duplex separatus, 138 

extirpation of, in carcinoma, 292 

fibroid tumors of, 244 

totalis, 140 

infantalis, 140 

inflammation of, 174 
chronic, 177 

inversion of, 236 
lateroflexion of, 234 
lateroversion of, 219 
malformations of, 137 
mucous polypi of, 273 
normal movements of, 14 
prolapsus of, 198 
• retroflexion of, 226 
retroversion of, 213 
rudimentary, 138 
sarcoma of, 277 
septus, 139 

sound in replacement of, 230 
subinvolution of, 177 
superin volution of, 142 
subseptus, 139 
unicornis, 138 

V 

Vagina, absence of, 90 
anatomy of, 5 
atresia of, 91 
cloaca of, 91 
diseases of, 90 
double, 91 

malformations of, 90 
operation to close, 132 
operation to make artificial, 96 
prolapsus of, 103 
prolapsus of treatment, 107 
rudimentary, 90 
smallness of, 91 
unilateral, 91 



Vaginal dilator, Sims', 96 
examination, 34 
fistula?, 122 
ovariotomy, 349 
Vaginismus, 100 

Sims' operation for, 101 
Vaginitis, 97 

therapeutics of, 423 
Varicose veins of vulva, 74 
Vesico-vaginal fistula, 123 

hernia, 104 
Vessels supplying genital organs, 22 
Vestibule, anatomy of, 4 
Volsellum forceps, 261 
Vulva, absence of, 64 

anatomy of, 1 

atresia of, 64 

carcinoma of, 72 

cysts of, 68 

diseases of, 64 

elephantiasis of, 69 

eruptive diseases of, 74 

fibroma of, 69 

hematoma of, 73 

hernia of, 67 

hyperaesthesia of, 85 

infantalis, 64 

inflammation of, 81 

lipoma of, 69 

lupus of, 71 

malformations of, 64 

neuroma of, 69 

oedema of, 74 

pruritus of, 75 

sarcoma of, 72 

tumors of, 68 

varicose veins, 74 
Vulvitis, 81 

therapeutics of, 423 

w 

Well's ovarian clamp, 357 

trocar, 355 
White's repositor, 240 
Wylie's cervical plug, 152 

z 
Zwanck's pessary, 208 



CATALOGUE 

OF 

HOMCEOPATHIC PUBLICATIONS 



OF 



GROSS & DELBRIDGE, 

48 Madison Street, Chicago. 



TEXT-BOOK OF MATERIA MEDICA, Char- 
acteristic, Analytical and Comparative. By 
A. C. Cowperthwaite, M. D., Ph. D., Professor of 
Materia Medica and Diseases of Women in the Ho- 
moeopathic Department of the State University of 
Iowa. Fourth edition, revised and enlarged, with 
Clinical Index, making a volume of 722 pages. 
Cloth, $5.00; sheep, $6.00. Postage, 32 cents. 

The first :di:ion of this Text-book -was issued four years ago, and 
received the ^meral commendation of the Homoeopathic profession. 
This edition has been much improved, and the work as it now appears 
cannot fail to be received with increased favor. The author has endeav- 
ored to furnish the beginner with the prominent features of the most 
important remedies, and to so arrange them as to facilitate their studv. 

The fact that a fourth edition of any work should be called for 
within the time which has elapsed since the issue of the first edition of 
the book under consideration, is sufficient evidence that it has met an 
appreciative demand. The text has been thoroughly revised, and about 
one hundred additional remedies incorporated. We can justly say that 
it is multum inj>arvo! — The Homoeopathic Times. 

In seven hundred pages Prof. Cowperthwaite gives a clear, but 
necessarily brief, synopsis of the characteristic symptoms of nearly four 
hundred drugs. Some remedies not in the second edition have been 
added, others thoroughly revised, and many new " comparisons " added. 
These comparisons are a new and special feature of Prof. Cowper- 
thwaite's book. — The Homoeopathic Physician. 

We believe this to be one of the best Text-books of Homoeopathic 
Materia Medica published, and heartily recommend it to the student 
and practitioner. — Physicians' 1 and Surgeons' 1 Investigator. 



GROSS & DELBRIDGE'S MEDICAL WORKS. 



THE SCIENCE AND ART OF OBSTET- 
RICS. By Sheldon Leavitt, M. D., Professor of 
Obstetrics and Diseases of Women in Hahnemann 
Medical College and Hospital, Chicago. 659 pages 
octavo. Price, cloth, $5.00; full sheep, $6.00. 
Postage, 32 cents. 

This work is intended to fill the want so long felt by Homoeopathic 
teachers of Obstetrics, students and practitioners, of a text-book which 
should deal with the subject as both a Science and Art, and embody 
the researches and improvements which have been made in this branch 
of Medicine during the past few years. 

The work of Dr. Leavitt has been carefully examined, both by Dr. 
Southwick and by myself, and both of us have formed a most favorable 
opinion of the ability and conscientiousness of the author. We shall 
both have much pleasure in recommending the book warmly to our 
students. — W. Wesselhoeft, Prof, of Obstetrics in Boston University. 

Prof. Leavitt has honored himself and the profession by his book. 
It will take high rank as a text-book, and prove most serviceable to the 
practitioner. — J. O. Sanders, M. D., Prof, of Obstetrics in the Cleveland 
Horn. College. 

We unhesitatingly place this book at the head of its department, 
and have no doubt it will become the text-book of all our colleges. — 
New York Medical Times. 

I have given Prof. Leavitt's Obstetrics a prominent place among 
my books of reference. I consider it o ic of the best text-books in our 
literature, and an honor to the publishers thereof. — E. M. Hale, M. D. 

I have read Prof. Leavitt's work on Obstetrics, and am delighted 
with it. — /. T. Talbot, M. D., Prof, of Surgery in Boston University. 

Prof. Leavitt has done his work thoroughly, showing great reading 
and yet more good judgment in accepting the good and discarding the 
evil. His diction is plain, so that he who reads may understand it, an 
advantage not found in every work which leaves the press.— North Am. 
Journal of Horn. 



GROSS & DELB RIDGE'S MEDICAL WORKS. 



DISEASES AND INJURIES OF THE EYE. 

A Practical Treatise on the Medical and Surgical 
Treatment of the Diseases and Injuries of the Eye. 
By J. H. BUFFUM, M. D., O. et A. Chir.; Professor 
of Ophthalmology and Otology in the Chicago Ho- 
moeopathic Medical College. 428 pages. Containing 
150 wood engravings and 25 colored lithographs. 
Cloth, $4.50. Postage, 20 cents. 

This work is intended as a text-book for students, and a hand-book 
for the general practitioner. It is written in the clear and practical style 
so characteristic of the many other contributions to medical literature 
by the author. The Homoeopathic treatment given has been clearly in- 
dicated, and only those remedies are considered which have borne the 
test in extensive hospital and private practice. 

As avant courier of the coming year, sure to be full of good things, 
comes this new candidate for public favor. "We have taken it up with 
interest, scanned its well-filled pages, and now lay it down with a feeling 
of satisfaction because it has met our expectations. For the first time 
we have a representative work in this department. It is well- written 
and handsomely printed. — Medical Advance. 

Chicago has spoken again, and this time through the medium of its 
well-known oculist, Dr. Buffum. The book is well written and practi- 
cal ; the descriptions are concise and to the point. — New England Medi- 
cal Gazette. 

This book is the joint production of New York and Chicago — an 
Eastern man in a Western land. We find in it much to commend — 
nothing to condemn. The style is very happy, and presents us with a 
specimen of English which is clear and plain. We do not think there 
is an ambiguous expression in the entire book. The one hundred and 
fifty well-executed engravings light it up so that its lessons amount al- 
most to demonstrations. Its twenty-five colored lithographs illuminate 
it so that a diagnosis becomes easy and almost certain. There has been 
a demand for just such a work as this, and the demand could not have 
been better answered. — Medical Era. 

Great credit is due Dr. Buffum for his able condensation of the pres- 
ent views pertaining to ophthalmic science. It will be of much service 
and value to students and general practitioners. Only words of praise 
are rendered the publishers for the manner in which they have done 
their work. — Prof. G. S. Norton, in North American Journal of Homoe- 
opathy for November, 1883. 

Dr. Buffum has succeeded with rare skill in giving to the reader 
an admirable monograph upon the eye. — Dr. F. Park Lewis, in Medical 
Counselor. 

I shall recommend it to our class in preference to all others. — W. 
A. Phillips, M. D., Prof, of Ophthalmology and Otology in Cleveland 
Horn. Med. College. 



GROSS & DELBRIDGE'S MEDICAL WORKS. 



LECTURES ON FEVERS. By J. R. Kippax, 
M. D., LL.B., Professor of Principles and Practice 
of Medicine in the Chicago Homoeopathic Medical 
College; Clinical Lecturer and Visiting Physician to 
the Cook County Hospital; Author of " Handbook 
of Skin Diseases," etc. 460 pages. Illustrated. 
$4.50. Postage, 20 cents. 

These Lectures have been published at the request of students and 
practitioners who have been from time to time under the instruction of 
the Author, and who have expressed a desire to have them prepared in 
the present form. They embrace every form of Fever, its Definition, 
Histology, Etiology, Pathology and Homoeopathic Treatment, making 
a most important and valuable addition to our literature. Printed in 
large type and on good paper. 

We have derived more real information — more of "just what we 
have long needed" — in a month's ownership of this valuable work than 
from any other book in our possession. No homoeopathic physician 
nor enlightened allopath will regret the purchase of this work. We 
don't see how we have got along without it so long. — Dr. Fisher, in 
Southern Homoeopathic Journal. 

It gives us pleasure to speak in high terms of commendation of 
these lectures on Fevers. No wonder they took with the students. 
They are written in a plain style, and therefore more easily impressed 
upon the mind. The charts all through the work are a great aid to 
memorize each, and the differential diagnosis has been treated con 
amore. The publishers have done their part well, as usual, and deserve 
the thanks of us who must be saving of our eyesight. — Dr. Liiienihal, 
in North American Journal of Homoeopathy. 

This work cannot fail to be a valuable text-book, and will doubt- 
less be adopted by the Medical Colleges for this purpose. — New York 
Medical Times. 

We commend this work to our readers. — New England Medical 
Gazette. 



GROSS & DELBRIDGKS MEDICAL WORKS. 



KEY-NOTES OF MEDICAL PRACTICE. 

By Charles Gatchell, M. D., formerly Professor 
of the Theory and Practice of Medicine, University 
of Michigan ; Attending Physician to Cook County 
Hospital; Author of " How to Feed the Sick," 
" Treatment of Cholera," " Haschisch," etc. Pocket 
Book. Flexible leather. 217 pages. Fourth edi- 
tion, revised and enlarged. $2.00. Postage, 4 cents. 

This is a complete hand-book of Medicine, Surgery and Obstetrics 
and is in such form as to actually go into the pocket, making it a 
veritable vade-mecum. 

When I began practice such a book would have been worth a 
hundred dollars to me. — A. C. Cozvperthzvaite, M. D. 

Really an excellent compendium of ail that the practitioner wants 
to have at hand. — Dr. Richard Hughes, England. 

This is the book for which I have been waiting for many years. — 
Dr. Sanders. 

The exceeding usefulness of this handsome pocket book, which is 
designed to be taken out and referred to as an account book, makes 
Prof. Gatchell's condensation and selection of just what one wishes at a 
moment's notice the best guide in emergencies which the practitioner 
can have on his rounds. As a ready reference compendium we have 
never seen its equal. The key-notes for the selection of remedies are 
really what they are called, and the general measures recommended 
will be verified in practice. No one except a trained teacher, literary 
craftsman, careful student and successful physician could have collated 
such a handy epitome of Practical Medicine. — North Am. fourn al of 
Horn. 

Prof. Gatchell has written what might be styled an Emergency Prac- 
tice. He gives attention to all those diseases upon which a young physi- 
cian may be called for an opinion at any moment. He omits all theor- 
izing and gives in the tersest possible style just what a doctor wants to 
know when he is face to face with a critical case. Here is a book which 
looks just like a private memorandum book; -which nobody need feel sensitive 
about fulling out and consulting . We -wish -we could put a copy of this 
book into every studenfs ha?id that is about to graduate this Spring. It 
would aid him to become a skilled practitioner, if he would thoughtfully 
consult it in every case in which he was called, and would thus do much 
to prevent hasty and ill-considered prescribing. — The American Homceo 
path. 



GROSS & DELBRIDGE'S MEDICAL WORKS. 



PRACTITIONER'S GUIDE TO URINARY 
ANALYSIS. By Clifford Mitchell, A. B. 
(Harv.), M. D., Professor of Chemistry, Chicago 
Homoeopathic College; Author of "Physicians' 
Chemistry," " Manual of Urinary Analysis," " Clini- 
cal Significance of Urine," "Manual of Simple 
Chemical Tests," etc. Second edition, thoroughly 
revised. 12mo. Cloth. $1.50. Postage, 8 cents. 

This neat volume, by its precision and clearness of language, 
by the excellent taste shown in the arrangement of its contents, and 
by the many evidences of thoroughness and good sense, with which 
the subject of Urinary Analysis is treated, recommends itself at or.ce 
to the reader's favorable consideration. 

The book is certainly adapted to the needs of a vast majority ot 
medical men, many of whom are but poorly posted on Urinary Analysis, 
even though they are fully aware of the importance of careful exami- 
nations of the urine in order to correctly diagnosticate many cases brought 
to them for treatment. — Medical Counselor. 

Of all the Manuals — and their name is legion — prepai-ed to aid in the 
work of Urinary Analysis we believe this to be second to none. For 
plainness and simplicity it is unexcelled. — Medical Advance. 

I have already had occasion to make use of Mitchell's " Guide to 
Urinary Analysis," which I consider to be the best, the clearest and the 
fullest work on the subject yet published, containing a remarkable 
amount of information, in a most convenient form. — Ck. Gatchell, M. D. 

I should call your " Practitioner's Guide to Urinary Analysis" a faith- 
ful execution of what its title page promises. There is no empty talking 
nor wishy-washy verbiage in it. It is a square, solid and reliable business 
transaction. And you have done this work in a very clear and lucid 
manner, which is a gift not very frequently found among writers. — 
C. G. Rane, Author of Rune's Pathology. 



GROSS & DELBRIDGKS MEDICAL WORKS. 



THE PHYSICIAN'S CHEMISTRY. By Clif- 
ford Mitchell, A. B., M. D., Author of "Stu- 
dent's Manual of Urinary Analysis," "Clinical Sig- 
nificance of Urine," "Practitioner's Guide to Urinary 
Analysis." 1886. 301 pages. Price, $1.50. Post- 
age, 10 cents. 

This book was made for the medical student and physician. The 
aim has been to give much information in as small space as possible, and 
to simplify Chemical Theory so that the beginner can learn to read 
formulae without a teacher. 

Professor Mitchell has done a real service in bringing out this book. 
We have examined it at some length, and find it commendable in all 
respects. The theory of inorganic chemistry is followed by a condensed 
statement of all that will usually be required by tne physician concern- 
ing chemical bodies, organic as well as inorganic. The chapter on the 
examination of urine is valuable. The last half of the book is taken 
up chiefly by a well-digested Toxicology and an appendix of important 
chemical memoranda. The book is well printed and bound, and pre- 
sents a very handsome appearance. — Homoeopathic Recorder. 

It is well arranged as a practical college text-book, and we are 
pleased to see a work on Chemistry by one of our teachers which may 
with advantage be adopted by at least all our colleges. — Medical Ad- 
vance. 

It is a most excellent ready reference book for the practitioner who 
has but short time at his disposal, and must have the information he 
seeks close at hand. — Homoeopathic Physician. 

The author of this practical work has carried out his aim well, in 
giving his information in as small space as possible. He has simplified 
Chemical Theory so that a beginner can understand it. We heartily 
commend the book to practitioners as well as to students. — -N. T. Med. 
Times. 

I shall take pleasure in recommending it to the students of the 
Minnesota Homoeopathic Medical College. — Prof. S. Francis Broivn. 

The work would be a happy substitute for many of the text-books 
in Chemistry now in vogue, with their prolixity of detail and specula- 
tion, and repetition of old and trite and worn-out experiments. We 
commend the Physician's Chemistry to our readers. — St. Louis Periscope. 



GROSS & DELBRIDGKS MEDICAL WORKS. 



THE AMERICAN HOMCEOPATHIC DIS- 
PENSATORY. Designed as a Text-Book for the 
Physician, Student and Druggist. By T. D. WIL- 
LIAMS, M. D., Member Illinois State Pharmaceutical 
Association, Active Member American Public Health 
Association. 713 pages. Octavo. Half leather 
$4.00. Postage, 30 cents. 

This important work is written in a plain and concise manner by a 
gentleman of large experience as a pharmacist, and who seems therefore 
to have fully comprehended the want of a reliable and scientific Dispen- 
satory. 

One of the special features which characterizes this work, and which 
to a certain extent accounts for its length, is the enumeration under 
each drug of the several preparations employed, with explicit directions 
for each, instead of the plan adopted in all other similar works, of refer- 
ring to stated classification to be found elsewhere. There can be no doubt 
that this method will be found much more convenient, especially to those 
who are not familar with the special manipulation required, and the in- 
creased size and cost of the volume will be overlooked. This work is 
evidently that of a master hand, and will undoubtedly be of great service 
to such as may require it. — New Tork Medical Times. 

A careful scrutiny of the body of the work shows that the author 
has worthily fulfilled the task set before him. No one who desires to 
prepare medicines according to the homoeopathic formulary will be be- 
fogged by the directions given here. Everything is plain, orderly, 
judicious ; while the typographical neatness of the work adds greatly 
to the pleasure and ease with which it may be consulted. — Dr. Winter- 
burn, in American Homoeofathist. 

The work is a very satisfactory one. — The. Medical Record. 

It will be a long time before a Dispensatory equally valuable will 
be given to the profession, and it is a work ev.ery physician should have 
in his library.— Dr. E. M. Hale. 



GROSS & DELBRIDGE'S MEDICAL WORKS. 



A PHYSIOLOGICAL MATERIA MEDICA. 

Comprising the Physiological Action of our Rem- 
edies, their Characteristic Indications and their Phar- 
macology. By W. H. Burt, M. D. Octavo. 
Fourth edition. Cloth, $7.00; sheep, $8.00. 

Dr. Burt has brought together in a compact and well-arranged form 
an immense amount of information. The profession will fully appre- 
ciate the labor and skill with which the author has presented the physio- 
logical and pathological action of each drug on the organism. — New 
York Medical Times. 

We are sure that Dr. Burt's new work will have deservedly a rapid 
sale. Paper and printing leave nothing to be desired. May the pub- 
lishers never falter in such laudable work, and the eyes of the readers 
will bless them forever. — Dr. Lilienthal, in North American Journal of 
Homoeopathy. 

An enthusiastic yearning for the whys and wherefores of our won- 
drous Therapeutic art has brought Dr. Burt to the front again among 
the best bookmakers of our time. — St. Louis Clinical Review. 

Dr. Burt has enriched our literature with many valuable contri- 
butions, and the work before us gives proof of the value of his well- 
directed labors. — Detroit Medical Observer. 

We can recommend the book as full of interesting and profitable 
reading. — Hahnemannian Monthly. 

Dr. Burt has the power of sifting the tares from the wheat. — Chica- 
go Medical Times. 

We cordially recommend Dr. Burt's book. — New England Medical 
Gazette. 

Have just received Burt's Materia Medica. It is a work long 
needed, and the printing and binding are a credit to the house. — R. W. 
Nelson, M. D. 

It is a key-stone of medical study, and the printing and binding are 
the very best. — G. H. Morrison, M. D. 

The work is a credit to Chicago. — Medical Investigator. 

CLINICAL COMPANION to " The Physiolog- 
ical Materia Medica." Being a Compendium of 
Diseases, their Homoeopathic and Accessory Treat- 
ment, with Valuable Tables and Practical Hints on 
Etiology, Pathology, Hygiene, etc. By W. H. BURT, 
M. D. 252 pages. Illustrated. Price, cloth, $2.50; 
flexible leather, $3.00. 



10 GROSS & DELBRIDGE'S MEDICAL WORKS. 

A COMPLETE MINOR SURGERY. The 

Physician's Vade-Mecum. Including a Treatise on 
Venereal Diseases. Just published. By E. C. FRANK- 
LIN, M. D., late Professor of Surgery in the Univer- 
sity of Michigan; Author of "Science and Art of 
Surgery," " Spinal Curvature," etc. Illustrated with 
260 wood cuts. 423 pages. Octavo. Price, cloth, 
$4.00; sheep, $4.50. Postage, 19 cents. 

Among our American writers Prof. Franklin ranks high, and as an 
author he has contributed his share of the American classics. He has 
the rare faculty of teaching others how they, too, may become surgeons. 
His manner of imparting is clear and lucid. With this book in posses- 
sion no practitioner will need any other text-book on minor surgery. It 
is full and complete, and every bandage and dressing and instrument 
known or used is illustrated. It also contains full directions of how to 
make post-mortem examinations, for which every doctor will thank 
him. If you have no work on minor surgery, you can do no better than 
to purchase this, which is fresh from the hands of a master- workman. — 
Clinical Review. 

The author's large experience as an operator and as a teacher will 
insure this volume a kindly reception at the hands of his colleagues ; 
the knowledge that a book is based upon actual experience at the bed- 
side, embodying the results of extended personal observation, gives a 
peculiar emphasis to its teaching and secures a respectful hearing even 
from those who have good reasons for holding views other than those 
advanced by the author. — Medical Counselor. 

After giving us just a little physiology, our good old friend strikes 
right out and gives us a thorough manual on bandaging, and we are 
glad to see, having the country doctor always in our mind's eye, that 
many of the old-fashioned, complicated modes of bandaging have been 
left out: the handkerchief system of Mayor (page 95) deserves recom- 
mendation, for " the handkerchief is found everywhere." — Dr. Lilienthal. 

A MANUAL OF VENEREAL DISEASES. 

Being a Condensed Description of those Affections 
and the Homoeopathic Treatment. By E. C. FRANK- 
LIN, M. D., late Professor of Surgery in the Homoe- 
opathic Department of the University of Michigan; 
Surgeon to the University Homoeopathic Hospital; 
Author of "Science and Art of Surgery," "A Com- 
plete Minor Surgery," etc. Octavo. Price, $1.25. 
Postage, 7 cents. 
The work is written clearly, the description of disease is " to the 
point," the diagnostic symptoms cannot well be misunderstood, and the 
indications for the use of the remedies considered are selected with care 
and sound judgment. 



GROSS & DELBRIDGE'S MEDICAL WORKS. 11 



RUDDOCK'S FAMILY DOCTOR. Being a 
Reprint of Dr. Ruddock's " Vade-Mecum," "Diseases 
of Women," "Diseases of Infants and Children" and 
" Essentials of Diet." With Notes and Additional 
Chapters, by James E. GROSS, M. D. 734 pages. 
Octavo. Cloth, $3.00; full morocco, $4.00. Post- 
age, 30 cents. 

Dr. Ruddock's popular books have had a remarkable sale, both in 
England and America. This book is a handsome reprint of the -whole, 
with notes and chapters adapting it to the American public. Every 
disease has received full attention, special care having been given to 
those of women and children. 

Dr. Ruddock's well-known Vade-Mecum, Diseases of Women, Dis- 
eases of Infants and Children and his Essentials of Diet have been re- 
arranged and extended by Dr. Gross, of the Chicago Medical Era, 
and are now published in one handsome volume, under the title of 
"Ruddock's Family Doctor." These works have already benefited thou- 
sands upon thousands, and in the new dress in which they are now pre- 
sented deserve and cannot fail to have a lai-ge circulation. — American 
Homceopatliist. 

This splendid volume is the most complete book for the family 
that has ever been published for our school, and I most heartily recom- 
mend it to alh—E. M. Hale, M. D. 

" Ruddock's Family Doctor," edited by Dr. Gross, is in my opinion 
to be preferred above all other works for family use. — J. H. Buffum, M. 
D., Prof, of Diseases of the Eye and Ear in the Chicago Homoeopathic 
Med. College. 

In the editor's preface to "Dr. Ruddock's Family Doctor," the 
entire story as to its usefulness has been told, namely, that the author's 
popular writings are unequaled — with the exception that in the com- 
pilation they have been "Americanized;" that is to say, they have been 
made even more domestic by the additional chapters and notes of Dr. 
Gross. After a careful reading it is my opinion, as a guide for domestic 
treatment, that "Dr. Ruddock's Family Doctor" is positively unexcelled. 
— T. D. Williams, M. D., Author of American Homoeopathic Dispen- 
satory. 

We can commend it in good faith to all our readers, strict Hahne- 
mannians or otherwise. — North American Journal of Homoeopathy. 

Full to overflowing of valuable material gathered from all sources. 
As an exponent of the best treatment of disease, in brief form and up 
to date, it is not surpassed. — Hahnemannian Monthly. 

I consider it the best medical work for the use of families yet pub- 
lished. It is full of practical hints. — John R. Kippax, M. D., LL. B., 
Prof, of Principles and Practice of Medicine, Chicago Homoeopathic Med. 
College. 



GROSS & DELBRIDGE'S MEDICAL WORKS. 

HOW TO FEED THE SICK. By Charles 
GATCHELL, M. D., Author of "Key-Notes of Med- 
ical Practice," "Treatment of Cholera," " Haschisch," 
etc.; Attending Physician to Cook County Hospital. 
Third edition, enlarged. Cloth, $1.25. Postage, 8 cts. 

Every practitioner of medicine, of whatever school of practice, can 
find in this work many practical hints that he cannot well afford to 
neglect. Success in the treatment of many chronic diseases often de- 
pends upon " how to feed the sick." It should grace every library in the 
land . — Periscope. 

Professor Charles Gatchell's " How to Feed the Sick " is the best 
book on the subject for the people. It contains in 160 pages an astonish- 
ing amount of condensed information on a subject of great importance, 
and one but little understood. Its style is admirable, pithy, and to the 
point. The book has no padding about it, and deserves an immense 
sale. — .9. O.L. Potter, M. D., Author of Index of Comparative Therapeu- 
tics, etc. 

The first edition of this little work, which has had a wide distribu- 
tion, appeared under the title of "Doctor, What Shall I Eat?" and drew 
from both medical and lay journals the high tribute of praise which it 
deserves, in still larger measure, in its present revised and enlarged 
form. The work is eminently practical, simple in its details, clear and 
precise in its formulae, and suited to the needs alike of doctor and 
patient. — Min nesota Tribune. 

This is a hand-book of diet in disease prepared by a thorough physi- 
cian. Florence Nightingale said, " To give food and stimulants in the 
way, at the time, of the kind, with the cooking and preparing that will 
best enable the poor, enfeebled digestion to assimilate it, is one of the 
great arts of nursing." She might have added that it was a great part 
of medicine. The work has already passed through three editions. It 
is dedicated to the trained nurses of America. A good idea of its scope 
may be obtained by an enumeration of the heads of the various chap- 
ters — How to Feed the Baby; the Care of Milk; Diet in Cholera In- 
fantum; How to Feed Fever Patients; Diet in Dyspepsia; Diet in Con- 
stipation ; Diet in Consumption ; Rectal Alimentation ; Diet in Diabetes ; 
Milk Cure ; Diet in Bright's Disease ; Diet in Gravel ; Diet of Travel- 
ers; Diet for the Corpulent; Diet in Rheumatism; Diet in Asthma; 
Diet in Heart Disease; Diet in Diarrhoea, Dysentery, Cholera; Diet 
in Diphtheria; Diet in Inflammation of the Stomach; Diet in Bilious- 
ness; Diet in Convalescence; Recipes, Soups and Broths; Miscella- 
neous. We place a high estimate upon this work because of the attain- 
ments of the author as a physician and a writer. — Health Journal. 



GROSS & DELBRIDGE'S MEDICAL WORKS. 13 



AN INDEX OF COMPARATIVE THERA- 
PEUTICS. With a Pronouncing Dose-List in the 
Genitive Case, a Homoeopathic Dose-List, Tables of 
Differential Diagnosis, Weights and Measures, Mem- 
oranda Concerning Clinical Thermometry, Incompat- 
ibility of Medicines, Ethics, Obstetrics, Poisons, An- 
aesthetics, Urinary Examinations, Homoeopathic 
Pharmacology and Nomenclature, etc. By Samuel 
O. L. Potter, A. M., M. D., Author of "Speech and 
Its Defects," "Compend of Anatomy," "Compend of 
Materia Medica and Therapeutics," etc. Cloth, $2.00 ; 
leather tuck, $2.50. Postage, 8 cents. 

The leading feature of this book is its comparative tabular arrange- 
ment of the therapeutics of the two great medical schools. Under each 
disease are placed in parallel columns the remedies recommended by 
the most eminent and liberal teachers in both branches of the profession. 
By a simple arrangement of the type used, there are shown at a glance 
the remedies used by both schools, as well as the remedies peculiar to 
each, for any given morbid condition. Over forty prominent teachers 
are referred to, besides occasional references to more than thirty others. 
In the first class are Bartholow, Ringer, Phillips, Piffard, Trousseau 
and Waring of the old school; Hempel, Hughes, Hale, Ruddock and 
Jousset among modern homoeopathic authorities. 

Dr. Potter's compilation must be the result of a large amount of 
painstaking and accurate work, and will be appreciated. As an index 
it is very elaborate and serviceable. — Nexv England Medical Gazette. 

The work is really a midtum in farvo; as an index it is exhaustive, 
and very often it supplies in few words the very information that is 
wanted. — British Journal of Hcunceopathy. 

I am much pleased with your Index. It is strong and will find 
sale among old as well as new school men. — Dr. J. P. Dake, Nashville, 
Ten n. 

It will furnish the busy practitioner with a summary of immense 
practical value. — Dr. H. M. Paine, Albany, N. T. 

It will be held in high appreciation by a large class of practition- 
ers." — Dr. C. P. Hart, Wyoming, O. 

I like the idea very much; besides giving many valuable hints to 
the practical physician, it is very interesting from a theoretical point of 
view. — Dr. H. C. Clapp, Boston. 



14 ROSS. & DELBRTDGE'S MEDICAL WORKS. 



ANTISEPTIC MEDICATION; or Declats 
Method. By Nicho. Francis Cooke, M. D., 
LL. D. Second edition. Cloth. $1.00. Postage, 
5 cents. 

The second edition of this important work is now ready. It is the 
first and must continue to be for some time the only treatise on this vitally 
important subject in the English language. It is plain and practical. 
Though written only for the physician, it cannot fail to attract attention 
from the intelligent layman. 

In the introduction may be found a history of antiseptic medication, 
the controversy between Declat, Lemaire and Tyndal, a brief sketch 
of Declat's life, and the theory on which the phenic-acid treatment is 
based. In the work proper he begins by giving a description of the 
various preparations of phenic acid, then of its physiological action 
when applied externally and when taken internally, and then he gives a 
resurhe of the physiological symptoms evinced in the nervous system, 
vascular system, respiratory system, chylopcetic system, and genito- 
urinary system. Of the methods of administering it he mentions five : 
1. By the mouth; 2. By the rectum; 3. By the-air passages; 4. Endermic; 
5. The hvpodermic method. The latter method he most enthusiastic- 
ally supports, and gives special instructions as to the use of the hypo- 
dermic syringe. Then follows a history of the cases treated by Dr. 
Cooke since 1^81, and the results of treatment, and among them were 
cases of tuberculosis, cancer, septicaemia, eczema, malarial fever, diphthe- 
ria, hay fever, etc. The book is well printed in good, clear type, with 
wide margns. 



THE BABY. How to Keep It Well. By 
J. B. Dunham, M. D. Cloth. 50 cents. Postage, 
5 cents. 

How to keep the baby well is a branch of knowledge rather more 
neglected than how to treat the baby when ill ; but it is a most important 
branch of knowledge, and is here treated of with a common-sense re- 
freshing to encounter. The old nurse of other days would doubtless 
regard many of its instructions with wide-eyed horror, such as the for- 
bidding of the traditional bath within a half-hour of birth, and the sub- 
stitution of oil in its stead ; the doing away with the abdominal band, and 
the injunctions against too frequent nursing ; but the young mother of to- 
day is somewhat emancipated from the thralldom of nurses and not dis- 
inclined to profit by the wise teachings here so pleasantly offered. — New 
England Med. Gazette. 



GROSS & DELBRIDGE'S MED.CAL WORKS. 15 

-BLESS THEE, BULLY DOCTOR!" By M. 

E. DlCUS, M. D. Illustrated by 100 finely executed 
wood cuts. Second edition. 50 cents. Postage, 
3 cents. 

This is certainly the most extraordinary book of the year. The 
author has gathered and put into book form the cream of the medical 
wit of the world, and the whole thing is profusely illustrated. 

THE ABDOMINAL BRAIN. By Leila G. 
BEDELL, M. D. 45 pages. Price, 20 cents. Post- 
age, 2 cents, 

The author belieyes that the sympathetic nervous system is the seat 
of organic and emotional life, as the cerebro -spinal nervous system is 
the seat of animal life, including thought, reason, judgment, perception, 
and will. Mind, according to Dr. Bedell, is the joint production of the 
two nervous systems, the cerebro-spinal and the sympathetic. To the 
latter she gives the name first given bv Bichat — tin abdominal brain. 
The cerebro-spinal system is stronger in men, and the sympathetic is 
stronger in women ; and according to Dr. Bedell's theory, in the repro- 
duction of our kind the mother contributes the organic part of our con- 
stitution, and the father the cerebro-spinal. The author has evidently 
given much thought to this subject, and she works out her case with 
great ingenuity and cogencv. 

THE PHYSICIAN'S CONDENSED AC- 
COUNT BOOK. An Epitomized System of Book- 
keeping, avoiding the necessity of separate Journal, 
Day Book and Ledger, combining system, accuracy 
and easy reference with a minimum of labor. 272 
pages. Price, $3.50, net. Sent postpaid. Send for 
sample page. 

THE PHYSICIAN'S DAY BOOK AND 
LEDGER. Arranged by T. D. Williams, M. D., 
Author of "American Homoeopathic Dispensatory." 
Price, $2.00, net. Sent postpaid. Sample pages 
sent on application. 

LABEL BOOK, for the Use of Physicians 

AND PHARMACISTS. Containing more than thirty- 
five hundred gummed labels in large, clear type, and 
bound in a neat and substantial manner. Price, 50 
cents, net. Sent postpaid. 



16 GROSS & DELBRIDGKS MEDICAL WORKS. 



THE MEDICAL ERA. A Monthly Journal of 
Medicine and Surgery. Edited by Drs. Gross and 
Gatchell. Each number contains 32 double-column 
pages. Terms, $2.00 a year, in advance. 

Everybody knows that the Era is one of the best conducted periodi- 
cals in our school. Long live the Medical Era! — The Medical Counselor. 

While in England I heard a great many expressions of interest in 
the Era's "Doctor Talks." Let them continue! — Dr. J. P. Dake. 

The " They Say " page of The Medical Era is one of the very best 
pages of our medical periodicals. It adds much to the spice and snap of 
the Era, and is quite a relief from the monotonous way the journals have 
of presenting their news items. — Southern Journal of Homoeopathy. 

The Medical Era is among the most welcome and congenial of our 
visitors, and we much enjoy the "Doctor," as reported by"Selah" 
His forms of expression might be looked upon as "Era-tic" by the over- 
finical; but his sentiments are as sound as his phrases are original. — 
Editor of the Nero England Medical Gazette. 

Send for a sample copy. Address: The Medical Era, 48 
Madison St., Chicago. 

DISCOUNTS. A discount of twenty (20) per cent 
will be allowed physicians on all books in this cata- 
logue, excepting those marked net. The same dis- 
count will be given on all other American Homoeopa- 
thic publications, with a few exceptions; and ten (10) 
per cent on English books. On all other medical books 
published in this country a discount of fifteen (15) per 
cent will be allowed. Orders for miscellaneous books 
will be filled by us at a discount of twenty-five (25) 
per cent from publishers' list. 

Remittances may be made by Bank Draft, P. O. Money 
Order, or Registered Letter at the risk of the under 
signed. 

GROSS & DELBRIDGE, 

48 Madison St., CHICAGO. 




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